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http://www.archive.org/details/whitemartinsgeniOOwhit 


PLATE  I. 


Inorganic  urinary  sediment.  A,  uric  acid  crystals;  B,  triple  phosphates,  tricalcium 
and  ammonia  magnesium;  C,  amorphous  urates;  D,  cystin;  E,  calcium  phosphate  crystals 
(simple  acid);  F,  phenylgiucosazone  crystals;  G,  indigo  matter  (alkaline  urine);  H,  calcium 
oxalate;  I,  hsmatoidin  (vesical  hemorrhage) ;  J,  bilirubin;  K,  calcium  carbonate;  L,  leucin; 
M,  tvrosin;   N,  ammonium  water  (various  types).      (Seepage  14.) 


WHITE  AND   MARTIN'S 

GENITO-URINARY   SURGERY 
AND    VENEREAL    DISEASES 


BY 

EDWARD  MARTIN,  A.M.,  M.D.,  F.A.C.S. 

JOHN  HHEA  BARTON  PROFESSOR  OF  SURGERY,  UNIVERSITY  OF  PENNSYLVANIA 

BENJAMIN  A.  THOMAS,  A.M.,  M.D.,  F.A.C.S. 

PROFESSOR   OF   UROLOGY   IN   THE   GRADUATE   SCHOOL  OF  MEDICINE   OF   THE    UNIVERSITY   OF 
PENNSYLVANIA;     INSTRUCTOR   IN   SURGERY,    UNIVERSITY   OF   PENNSYLVANIA;     GENITO- 
URINARY  SURGEON   TO   THE   PRESBYTERIAN   HOSPITAL,    PHILADELPHIA 

AND 

STIRLING  W.  MOORHEAD,  M.D.,  F.A.C.S. 

ASSISTANT   SURGEON   TO   THE  HOWARD   HOSPITAL    PHILADELPHIA 


ILLUSTRATED  WITH  424  ENGRAVINGS 
AND  21  COLORED  PLATES 


ELEVENTH  EDITION 


PHILADELPHIA   AND    LONDON 
J.  B.  LIPPINCOTT  COMPANY 


COPYRIGHT,  1897,  BY  J.  B.  LIPPINCOTT  COMPANT 
COPYRIGHT,  1900,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  1902,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  1905,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  1906,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  1907,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  I9IO,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  191 7,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,    I918,   BY  J.   B.    LIPPINCOTT  COMPANT 


Electrotyped  and  Printed  by  J.  B.  Lippincott  Company 
The  Washington  Square  Press,  Philadelphia,  U.  S.  A. 


oo 


en 


DEDICATED  TO 
J.  WILLIAM  WHITE,  M.D. 


PREFACE  TO  THE  TENTH  EDITION 

The  Tenth  Edition  of  this  book  appears  long  after  the  Ninth  has  been 
completely  exhausted,  not  for  any  lack  of  enterprise  and  urging  upon  the  part 
of  the  publishers,  but  because  the  authors  have  felt  that  the  work  must  be  reset, 
rewritten  and  reillustrated  to  fairly  and  yet  succinctly  present  the  views  and 
practices  of  to-day.  This  has  implied  a  careful  study  of  current  literature  and 
the  selection  therefrom  of  that  which  seems  of  permanent  value.  Also  an 
omission  of  much  that  the  fashion  of  the  day  has  passed  because  it  has  been 
supplanted  by  something  better. 

We  have  incorporated  in  the  text  a  brief  but  practical  presentation  of  vaccines 
and  serums;  tests  of  renal  function  which  are  found  most  serviceable  in  estimating 
operative  risks;  high  frequency  desiccation;  laboratory  diagnosis  of  syphilis  and 
control  of  treatment;  the  accepted  conservative  and  radical  treatment  of  prostatic 
hypertrophy  including  those  measures  which  have  done  so  much  to  lower 
mortality.  We  have  endeavored  fully  to  present  those  therapeutic  methods 
which  have  received  the  general  approval  of  the  clinically  experienced. 

We  have  not  found,  practically,  that  a  continued  positive  Wassermann  is  a 
condition  to  be  heroically  combated  at  the  expense  of  the  patient's  health,  nor 
are  we  in  accord  with  the  belief  that  old  symptomless  syphilitics  should  receive 
either  prolonged  and  continuous  treatment  or  intensive  courses  with  the  sole 
view  of  changing  their  Wassermann,  though  we  believe  that  such  patients  should 
be  given  intermittent  treatment  short  of  producing  drug  reaction  through  life 
and  that  mercury  and  iodides  should  be  the  basis  of  this  treatment. 

We  have  not  been  convinced  of  either  the  safety  or  the  special  value  of 
subdural  injections  in  cerebrospinal  syphilis,  ataxia  or  paresis. 

In  the  rewriting  the  original  authors  have  had  as  associates  Dr.  B.  A.  Thomas 
and  Dr.  S.  W.  Moorhead,  whose  special  work  has  made  them  thoroughly  con- 
versant with  the  present  laboratory  and  hospital  methods  of  diagnosis  and 
treatment. 

Edward  Martin. 
September,  191 7 


PREFACE  TO  THE  FIRST  EDITION. 


In  the  preparation  of  this  work  we  have  endeavored  to  present 
clearly  and  with  sufficient  detail  the  generally  accepted  teachings  of 
the  day  in  regard  to  the  pathology,  symptomatology,  diagnosis,  and 
treatment  of  syphilis  and  genito-urinary  diseases. 

We  have  exercised  the  author's  right  of  choice  in  estimating  the 
comparative  value  of  various  methods  of  treatment,  and  have  given 
chiefly  those  which  our  experience  has  led  us  to  prefer,  though  alter- 
native methods  are  usually  mentioned.  As  it  was  our  wish  to  make 
this  book  one  of  practical  use  to  the  physician,  much  space  has  been 
devoted  to  symptomatology,  diagnosis,  and  treatment.  The  patho- 
logical alterations  characteristic  of  the  diseases  and  injuries  described 
have  been  briefly  outlined,  avoiding  discussion  of  questions  still  un- 
settled. Historical  considerations  have  been  abbreviated  as  much  as 
possible,  and  references  have  been  omitted,  though  proper  credit  has 
been  given  for  special  methods  or  teachings. 

Emphasis  has  been  laid  upon  genito-urinary  antisepsis  and  the 
details  of  operative  and  manipulative  technique,  since  thorough  un- 
derstanding of  these  matters  must  form  the  foundation  for  all  good 
work  in  genito-urinary  surgery. 

The  modern  methods  of  examination  of  the  various  portions  of  the 
urinary  and  genital  systems  have  been  described  with  fulness,  since 
only  upon  familiarity  with  them  can  exact  diagnosis  and  scientific 
therapeutics  be  based. 

We  have  included  an  exceptionally  comprehensive  study  of  the 
changes  in  the  urine  and  its  constituents  produced  by  disease,  a  sub- 
ject so  intimately  connected  with  the  specialty  to  which  this  work  is 
devoted  as  to  desei've  much  more  attention  than  it  usually  receives 
in  surgical  text-books. 


vm  PEE  FACE. 

While  we  have  freely  discussed  established  facts  relating  to  the 
recognition  or  treatment  of  disease  or  injury,  and  important  theories 
bearing  on  questions  of  surgical  therapeutics,  we  have  tried  to  avoid 
the  confusion  which  is  apt  to  result  from  the  effort  to  be  encyclo- 
paedic. Our  views  have  been  put  in  such  form  as  to  be  of  practical 
use  to  the  general  practitioner  and  the  medical  student,  since  we  feel 
that  our  experience  as  hospital  surgeons  and  as  teachers  during  a 
number  of  years  has  familiarized  us  with  their  needs. 

In  the  sections  on  Stri(;ture  of  the  Urethra  and  Treatment  of 
Syphilis  we  have  used  portions  of  the  articles  on  those  subjects  con- 
tributed by  Dr.  White  to  the  volumes  on  Genito-Urinary  Diseases 
and  Syphilology  of  Morrow's  System  of  Genito-Urinary  Diseases, 
Syphilology,  and  Dermatology. 

We  must  also  express  our  thanks  to  Dr.  G.  H.  Fox  for  placing  at 
our  disposal  his  admirable  collection  of  photographs,  to  Messrs. 
Charles  Lentz  &  Sons,  of  Philadelphia,  for  the  illustrations  of  sur- 
gical instruments  contained  in  the  volume,  to  Mr.  Joseph  McCreery 
for  his  aid  in  the  correction  of  the  proofs,  to  Mr.  Samuel  Macmeney 
for  much  kindness  in  seeing  the  book  through  the  press,  and  to  Mr. 
G.  E.  H.  Weaver  for  preparation  of  the  index. 

J.  William  White. 
Edward  Martin. 

Philadelphia,  January,  1897. 


CONTENTS 


CHAPTER  I 


PAGE 


Examination  of  the  Patient  1 

Clinical  and  Laboratory  Examination — Examination  of  the  Genito-Urinary 
System — Cardinal  Symptoms  and  Signs. 

CHAPTER  II 
Examination    of   the    Urine   of    Exudates    and    Secretions    and    of    Kidney 

Function   14 

The  Glass  Tests — Qualitative  Examination — Determination  of  Kidney 
Function. 

CHAPTER  III 

Choice,  Care,  and  Sterilization  of  Instruments 24 

Choice  of  Instruments — Sterilization  of  Instruments — Care  of  Instru- 
ments. 

CHAPTER  IV 

Urethroscopy  31 

Anterior  Urethroscopy — Posterior  Urethroscopy — Topical  Applications 
and  Operations. 

CPIAPTER  V  . 

Cystoscopy    38 

Cystoscopes — Preparation  of  the  Patient — Technique  of  Cystoscopy — 
Normal  Cystoscopic  Appearance — Pathological  Appearances — Ureteros- 
copy — Ureteral  Catheterization — Rontgenology — Therapeutic  Applications 
of  the  Cystoscope. 

CHAPTER  VI 

Suppression,  Retention,  and  Incontinence  of  Urine  58 

Suppression   of   Urine — Retention  of  Urine — Incontinence   of   Urine. 

CHAPTER  VII 

Bacterin  and  Serum  Therapy  86 

Bacterins — Tuberculin — Tuberculin    Therapy — Sera — Normal    Serum. 

CHAPTER  VIII 

Surgery  of  the  Penis 91 

Anatomy  of  the  Penis — Anomalies  of  the  Penis — Anomalies  of  the  Prepuce 
— Injuries  of  the  Penis — Inflammatory  Affections  of  the  Penis — Chancroid 
— The   Clinical  Aspects  of   Chancroid — Tumors   of  the   Penis. 

CHAPTER  IX 

Surgery  of  the  Urethra  (Except  Urethritis  and  Stricture)   139 

The  Anatomy  of  the  Urethra — Malformations  of  the  Urethra — Hypospadia 
— Epispadia — Injuries  of  the  Urethra — Foreign  Bodies  in  the  Urethra — 
Urethral  Calculi — Fistula  of  the  Urethra — Urethral  Pouches  or  Divertic- 
ula— Urethral  Neoplasms — Diseases  of  Cowper's   Glands. 

ix 


X  CONTENTS 

CHAPTER  X 
Affections  Characterized  by  Urethral  Discharge 176 

Urethritis — Gonorrhoea — Typical  Acute  Gonorrhoea  of  the  Male  Urethra 
— Acute  Posterior  Urethritis — Treatment  of  Acute  Gonorrhoea  in  the 
Male — Systematic  Treatment  of  Acute  Gonorrhoea — Hygienic  Measures — 
Internal  Medication — Local  Treatment — Acute  Posterior  Urethritis — 
Chronic  Gonorrhoea — Treatment  of  Chronic  Urethritis — The  Question 
of  Cure. 

CHAPTER  XI 

Gonorrhcea  in  Women  and  Children 215 

Gonorrhoea  in  Women  —  Urethritis — Vulvitis  —  Bartholinitis  —  Metritis — 
Gonorrhoea]  Salpingitis  and  Oophoritis — Perimetritis — Vaginitis — The 
Question  of  Cure — Gonorrhoea  in  Children. 

CHAPTER  XII 

Complications  of  Gonorrhoea    228 

Extragenital  and  Systemic  Gonorrhoea — Gonorrhoea  of  the  Eye. 

CHAPTER  XIII 

Stricture  of  the  Urethra 245 

Clinical  Forms  of  Stricture — Location  of  Stricture — Changes  in  the 
Urethra — Symptoms  of  Stricture — Results  of  Stricture — Prognosis  of 
Stricture — Technique  of  Urethral  Instrumentation — Passage  of  Metal 
Instruments — Urethral  Fever- — Treatment  of  Organic  Stricture — Gradual 
Dilatation — Continuous  Dilatation — Urethrotomy — Summary  of  Treat- 
ment— Stricture  of  the  Female  Urethra. 

CHAPTER  XIV 
Surgery  of  the  Scrotum 290 

Anatomy,  Deformities,  Injuries,  and  Wounds — CEdema,  Emphysema, 
Cutaneous  Affections,  Gangrene — Elephantiasis — Tumors — Anatomy — 
Diseases  of  the  Scrotum. 

CHAPTER  XV 

Surgery  of  the  Testicles  297 

Anatomy — Anomalies  of  the  Testicle — -Anomalies  in  Migration — Con- 
tusions and  Wounds  of  the  Testicle — Infections  of  the  Testicle — Urethral 
Epididymitis — Epid-dymo-Orchitis  Complicating  Acute  Infectious  Dis- 
eases— Tuberculosis  of  the  Testicle — Syphilis  of  the  Testis  and  Epididymis 
— Tumors  of  the  Testicle — Hydrocele — Acute  Hydrocele — Chronic  Hy- 
drocele— Hydrocele  of  the  Tunica  Vaginalis  Testis — Hydrocele  of  the  Cord 
— Hydrocele  into  a  Hernial  Sac — Haematocele — Loose  Bodies  in  the 
Tunica  Vaginalis — Neuralgia  of  the  Testicles. 

CHAPTER  XVI 

Surgery  of  the  Spermatic  Cord  364 

Anatomy — Contusions  and  Wounds  of  the  Cord — Inflammation  of  the 
Cord — Tumors  of  the  Cord — Varicocele — Vasectomy — Vasopuncture  and 
Vasostomy. 


CONTENTS  Xi 

CHAPTER  XVII 

Surgery  of  the  Seminal  Vesicles  372 

Anatomy — Physiology — Acute  Vesiculitis  or  Spermatocystitis — Chronic 
Vesicuhtis — Tuberculosis  of  the  Seminal  Vesicles. 

CHAPTER  XVIII 

Surgery  of  the  Prostate  381 

Anatom}' — Physiology — Injuries  of  the  Prostate — Prostatitis — Irritable 
Prostate — Tuberculosis  of  the  Prostate — Hypertrophy  of  the  Prostate — 
Treatment  of  Hypertrophy  of  the  Prostate — Atrophy  of  the  Prostate — 
Prostatic  Calculi — Tumors  of  the  Prostate — Malignant  Diseases  of  the 
Prostate — Carcinoma — Sarcoma. 

CHAPTER  XIX 

Sexual  Weakness  and  Sterility 433 

Impotence — Sterility. 

CHAPTER  XX 

Psychopathia  Sexualis 455 

Sexual  Hypereesthesia — Sexual  Anaesthesia — Sexual  Paraesthesia. 

CHAPTER  XXI 

Surgery  of  the  Bladder 465 

Anatomy — Malformations  and  Malposition  of  the  Bladder — Wounds,  Con- 
tusions, and  Rupture  of  the  Bladder- — Fistula  of  the  Bladder. 

CHAPTER  XXII 

Surgery  of  the  Bladder — (Continued)    488 

Infections  of  the  Bladder — Cystitis — Tuberculosis  of  the  Bladder. 

CHAPTER  XXIII 

Surgery  of  the  Bladder — (Continued)    507 

Calculi  and  Foreign  Bodies — Calculus — Treatment  of  Vesical  Calculus — 
Foreign  Bodies  in  the  Bladder. 

CHAPTER  XXIV 

Surgery  of  the  Bl.a.dder — (Continued)    544 

Tumors — Treatment    of    Tumors    of    the    Bladder — Paravesical    Tumors. 

CHAPTER  XXV 

Surgery  of  the  Ureters   560 

Anatomy — Wounds  and  Rupture  of  the  Ureters — Ureteritis — Stricture 
of  the  Ureter — Calculus  of  the  Ureter — Fistula  of  the  Ureter — Tuber- 
culosis of   the  Ureter — Tumors   of  the   Ureter — Prolapse   of  the   Ureter. 

CHAPTER  XXVI 

Surgery  of  the  Kidney  '. 584 

Surgical  Anatomy — Physiology — Anomalies  of  the  Kidney — Nephroptosis 
— Injuries  of  the  Kidneys — Nephrectomy — Aneurism  of  the  Renal  Artery. 


xil  CONTENTS 

CHAPTER  XXVII 
Nephrolithiasis   618 

CHAPTER  XXVIII 
Renal  Infections  632 

CHAPTER  XXIX 

Renal  Tuberculosis  and  Fistul.e  652 

General  Tuberculosis  Aflfecting  the  Kidney — Localized  Renal  Tuberculosis 
— Renal  Fistulse. 

CHAPTER  XXX 
Hydronephrosis    (Uronephrosis)    660 

CHAPTER  XXXI 

Renal  Tumors  and  Parasites 668 

Parasites  of  the  Kidney. 

CHAPTER  XXXII 

Surgery  of  the  Suprarenal  Glands   683 

Tuberculosis — Abscess — Suprarenal   Tumors — Suprarenal    Cysts. 

CHAPTER  XXXIII 
Syphilis 687 

CHAPTER  XXXIV 

Syphilis — (Continued)     691 

The  Period  of  Primary  Incubation — The  Period  of  Primary  Lesion — 
Extragenital  Chancre — The  Prognosis  of  Chancre — The  Period  of  Sec- 
ondary Incubation. 

CHAPTER  XXXV 

Syphilis — (Continued)     713 

Syphilitic  Skin  Eruptions — Syphilitic  Affections  of  the  Appendages  of 
the  Skin. 

CHAPTER  XXXVI 
Syphilitic  Lesions  of  the  Mucous  Membranes  and  Alimentary  Tract  759 

CHAPTER  XXXVII 

Syphilis  of  the  Nervous   System    774 

Cerebral  Syphilis — Syphilis  of  the  Spinal   Cord — Syphilis  of  the  Nerves. 

CHAPTER  XXXVIII 

Syphilis  of  the  Eye,  Ear,  and  Respiratory  Tract 791 

Syphilis  of  the  Ear — Syphilis  of  the  Respiratory  Tract. 

CHAPTER  XXXIX 

Syphilis  of  the  Bones  and  Joints  803 

Syphilis  of  the  Joints. 


CONTENTS  xm 

CHAPTER  XL 

Syphilis  of  the  Muscles,  Cardiovascular  and  Lymphatic  Systems 811 

Syphilis  of  the  Muscles — Cardiovascular  System — Syphilis  of  the  Lym- 
phatic System. 

CHAPTER  XLI 
Syphilis    of    the    Uro-gexital    System    and    Mammary    Glaxd — Prognosis    of 

Syphilis    816 

Syphilis  of  the  Uro-genital  System. 

CHAPTER  XLII 
Hereditary   Syphilis    825 

CHAPTER  XLIII 

The  Laboratory  Diagnosis  of  Syphilis   846 

Theory  and  Technique  of  the  Wassermann  Reaction — Recognition  of  the 
Organism  of  Syphilis — The  Luetin  Reaction — Examination  of  the  Cerebro- 
spinal Fluid. 

CHAPTER  XLIV 

The  Treatment  of  Syphilis  860 

Prophylactic  Treatment — The  Abortive  Treatment — The  Constitutional 
Treatment  of  Syphilis — Systematic  Treatment  of  Syphilis — Treatment 
with  Arsenic — Administration  of  Mercury — The  Toxic  Effects  of  Mer- 
cury— The  Systematic  Treatment  by  Iodides — Local  Treatment  of  Syph- 
ilis— The  Treatment  of  Hereditary  Syphilis — Treatment  of  Syphilis  of 
the  Central  Nervous  System. 


ILLUSTRATIONS 

FIGURE  PAGE 

1.  Organic   urinary   constituents    15 

2.  Cylindrical    catheter    25 

3.  Elbowed  olivary  catheter   26 

4.  Phillips    catheter 26 

5.  Otis  urethrometer 26 

6.  KoUmann  anterior  and  posterior  dilators,  with  universal  handle 27 

7.  Kollmann  dilator,  with  copper  applied 27 

8.  Rectal  electrode   28 

9.  Anterior  ointment  depositor    28 

10.  Posterior  ointment  depositor 28 

11.  Intravenous  apparatus    28 

12.  Manhattan  table,  modified  for  cystoscopy  29 

13.  Mark's   anterior  urethroscope .  31 

14.  Table  arranged  for  urethroscopic  examination   '.  32 

15.  Anterior"urethroscopy  with  the  Mark  instrument 33 

16.  Mark's   posterior   urethroscope    (Swinburne   tube)    .■ 35 

17.  Buerger's    cysto-urethroscope    35 

18.  Posterior   urethroscopy,    Buerger   instrument    inserted 36 

19.  Electrolytic   needle 37 

20.  Brown-Buerger   cystoscope .  ,  .  .v.  ;  39 

21.  F.  Tilden  Brown  composite  cystoscope .  .  ^ 40 

22.  Otis   Brown   examining  cystoscope    40 

23.  Buerger   operating   cystoscope 40 

24.  Dry  cell  battery  provided  with  rheostat  and  ammeter 41 

25.  Position  for  cystoscopy 42 

26.  Introduction  of  cystoscope.     The  penis  is  drawn  upward  and  the  instrument 

allowed  to  slip  through  the  anterior  urethra  by  its  own  weight  44 

27.  Introductions   of  cystoscope.     The   fingers   of  the  left   hand   are   guiding 

the  instrument  into  the  membranous  urethra   44 

28.  Urethral    orifice   in    the    male    as    seen   through    indirect    inverted    image 

cystoscope    .  .  ; 46 

29.  Congenital  diverticulum  of  the  anterior  bladder  wall   SO 

30.  Types  of  ureteral  catheters    52 

31.  Cystoscopic   forceps    55 

32.  Young's   cystoscopic   rongeur    55 

33.  High-frequency  treatment  with  large  type  of  coil  machine    56 

34.  Tumor  formed  by  the   distended  bladder   60 

35.  Hypertrophied  bladder  from  urethral  stricture   62 

36.  Hypertrophy  of  the  lateral  and  median  lobes  of  the  prostate    67 

37.  Hypertrophy  of  the  lateral  lobes  of  the  prostate   68 

38.  Elbowed    catheter 70 

39.  Double-elbowed  catheter  70 

40.  Silver  prostatic  catheter   70 

41.  Insertion  of  catheter  with  aid  of  forceps  71 

42.  Malecot  soft  rubber  self-retaining  catheters    73 

43.  Retained  catheter   (straps  applied) 74 

XV 


xvi  ILLUSTRATIONS 

44.  Retained  catheter  (dressing  completed  with  bandage)    75 

45.  Apparatus  for  aspiration  of  bladder   Id 

46.  Box  for  sterilizing  catheters  with  formaldehyde   78 

47.  Urethral  electrode    84 

48.  Cross-sections  of  formalin-hardened  penis  at  different  levels  92 

49.  Structure  of  the  penis    93 

50.  Precocious  sexual   development    95 

51.  Double  penis 96 

52.  Hypertrophy  of  the  clitoris   97 

53.  Blocking  superficial  nerves  of  penis  100 

54.  Paraphimosis 102 

55.  Reduction  of  paraphimosis   103 

56.  Osseous  growth  of  the  penis 107 

57.  Balanitis 109 

58.  Herpes  of  the  glans Ill 

59.  Multiple  chancroids  of  the   coronary  sulcus    114 

60.  Chancroid  of  labium  major  115 

61.  Follicular   chancroid    116 

62.  Exulcerating  or  superficial  chancroid 117 

63.  Phagedsenic   chancroid    118 

64.  Chancroidal  phimosis    119 

65.  Chancroidal    bubo    121 

66.  Phimosis  caused  by  chancroid  of  the  meatus   126 

67.  Chancroidal   ulceration   of  an   incision   of   the   prepuce,    required   for   the 

relief   of   phimosis    127 

68.  Elephantiasis  arabum    131 

69.  Venereal  warts    132 

70.  Epithelioma    134 

71.  Epithelioma,  ulcerating  form   135 

72.  Epithelioma,  vegetating  form    135 

12).  Carcinoma  of  penis,  with  early  lymphatic  involvement    136 

74.  Epithelioma  with  glandular  involvement    136 

75.  Longitudinal  section,  showing  infiltration  of  a  carcinoma   137 

76.  Dissection  of  sagittally  cut  pelvis    140 

11 .  Diagrammatic  view  of  horizontal  section  of  bladder  and  urethra 141 

78.  Forms   of  penile  hypospadia    145 

79.  Peno-scrotal  hypospadia    146 

80.  Hypospadia     resembling  hermaphroditism   147 

81.  Penis  straightened  after  transverse  cut  of  lower  surface   148 

82.  Transverse  wound  sutured  longitudinally   148 

83.  Freshened  areas  and  incisions  made  in  forming  glandular  urethra.    Gland- 

ular urethra  closed  by  sutures 148 

84.  Beck's  operation  for  hypospadia   149 

85.  Flap    operation   for   hypospadia    150 

86.  Bevan's  operation  for  hypospadia 151 

87.  Usual  form  of  epispadia   152 

88.  Formation  of  glandular  urethra    153 

89.  Outlining  of  flaps  to  form  penile  urethra.     Cross-section  of  same,  show- 

ing the  direction  in  which  the  flaps  are  dissected 154 


ILLUSTRATIONS  xvii 

90.  Flaps    folded   over   and   held    in    position    by    sutures.      Cross-section    of 

same    154 

91.  Transverse  defect  between  penile  and  glandular  urethras   155 

92.  Foreskin  brought  up  behind  the  glans,  and  line  of  sutures  uniting  fresh- 

ened edges  of  transverse  defect  to  foreskin    155 

93.  Closing  posterior  defect    155 

94.  Suture  of  second  flap  155 

95.  Cured   epispadia    156 

96.  Urethral   forceps      163 

97.  Urethral  calculi  showing  segmentation    165 

98.  Urethral  calculi  showing  mushroom  shape   165 

99.  Closure  of  fistula   170 

100.  Papilloma  of  the  urethra  172 

101.  Suspensory  of  suitable  design   193 

102.  Copaiba  eruption    196 

103.  Urethral    syringe    196 

104.  Anterior  urethral  injection  by  patient   197 

105.  Irrigation  bag   200 

106.  Valentine    irrigator    200 

107.  Position  for  irrigation  with  patient  seated   201 

108.  Irrigation  of  the  anterior  urethra  with  the  patient  standing 202 

109.  Posterior    instillation    203 

1 10.  Paraurethral  sinus  at  meatus   205 

111.  KoUmann  posterior  dilator  in  use      209 

112.  Anterior  urethral  injection  210 

113.  Treatment  of  chronic  urethritis  with  heated  instruments   212 

114.  Short  straight  bougie   218 

115.  Gonorrhoeal   phimosis    229 

116.  Gonorrhoeal  paraphimosis    229 

117.  Bilateral  gonorrhoeal  buboes    230 

118.  Periurethral  abscess;  marked  swelling  of  prepuce    230 

119.  Epididymitis  with  hydrocele    233 

120.  Gonorrhoeal  conjunctivitis.     Swelling  of  the  lids  and  free  discharge   ....  236 

121.  Gonorrhoeal    conjunctivitis.      Infiltration    of    bulbar    and    palpebral    con- 

junctiva      237 

122.  Gonorrhoeal   conjunctivitis  passing   into   panophthalmitis    238 

123.  Subacute  gonorrhoeal  arthritis  of  knee   241 

124.  Bier's  hyperaemic  treatment  of  elbow  and  wrist   243 

125.  Gonorrhoeal  exostosis  of  the  os  calcis  244 

126.  Linear   strictures    248 

127.  Strictures  of  the  urethra   249 

128.  Diagrammatic  representation  of  the  three  common  varieties  of  urethral 

stricture    249 

129.  Traumatic  stricture   251 

130.  Cast  of  the  urethra   257 

131.  Gauge  for  urethral  instruments    257 

132.  Tip  of  catheter  just  entering  the  fixed  curve  of  the  urethra 263 

133.  Fixed   urethral   curve    264 

134.  Fixed    curve    of   the   urethra   obliterated    by    the    passage    of   a    straight 

instrument    264 


xviii  ILLUSTRATIONS 

135.  Passing  the  sound.     The  shaft  is  kept  parallel  to  Poupart's  ligament  till 

the  tip  has  reached  the  bulb    265 

136.  Passing  the  sound.     Handle  carried  to  the  midline   265 

137.  Passing   the   sound.      Handle    raised   to   bring   tip   into    the   membranous 

urethra    266 

138.  Passing  the  sound.     Handle  carried  toward  patient's  feet,  while  pressure 

is  made  at  the  root  of  the  penis  to  assist  in  obliterating  the  fixed  curve 

of  the  urethra 267 

139.  Position  of  sound  when  tip  has  entered  the  bladder 267 

140.  Chart  of  patient  with  acute  single  paroxysmal  urethral  fever 270 

141.  Tunnelled    catheter    272 

142.  Method  of  passing  a  filiform  bougie  through  a  small  stricture 275 

143.  Filiform  whalebone  bougie  tied  in  the  urethra  after  entering  the  stricture  276 

144.  Method  of  passing  Gouley's  tunnelled  catheter 276 

145.  Urethrotomy  with  Maisonneuve's  urethrotome    279 

146.  Urethrotomy  with   Gerster's   urethrotome    281 

147.  Crossed  of  the  perineum  bandage    282 

148.  Syme's  grooved  staff 283 

149.  Teale's  probe-ended  gorget    284 

150.  Elephantiasis  of  the  penis  and  scrotum,  showing  the  result  of  the  opera- 

tion      294 

151.  "  Coal-tar  worker's  cancer "  of  the  scrotum   296 

J^^-    I  Left    testis    298 

154.  The  lobules  of  the  testis 299 

155.  Efferent   canal 299 

156.  Undescended   testis    303 

157.  Second  step  in  operation  for  undescended  testicle  306 

158.  Showing   floor   of   inguinal    canal    split    from   the    internal    inguinal    ring 

to   the    pubis    307 

159.  Diagram  of  the  transplantation  of  vas  deferens  and  spermatic  vessels..   308 

160.  Showing  the  size  and  relative  position  of  the  testicle  and  epididymis   in 

acute  epididymitis 317 

161.  Epididymitis,  right  side   '. 318 

162.  Epididymitis  suspensory  bandage    320 

163.  Adhesive  strip  for  the  support  of  scrotum  322 

164.  Suppurative    epididymo-orchitis     327 

165.  Abscess  of  epididymis    327 

166.  Tuberculous    epididymitis    329 

167.  Tuberculosis  of  the  testicle 330 

168.  Gumma    of   testicle    334 

169.  Lymphosarcoma  of  the  testicle    335 

170.  Sarcoma  (teratoma)  of  the  testicle   336 

171.  Carcinoma  (teratoma)   of  the  testicle  337 

172.  Cystoma   (teratoma)  of  the  testicle    338 

173.  Cancer  (teratoma  of  the  right  testicle)    339 

174.  Intravaginal    spermatocele    341 

175.  Encysted    hydrocele     342 

176.  Multilocular  cyst  of  the  epididymis   342 

177.  Vertical  section  of  hydrocele  347 

178.  Hydrocele 348 


ILLUSTRATIONS  xix 

179.  Vertical    section   of   a    hydrocele,    showing   the    testicle    b'ing   below   the 

cyst    349 

180.  Inguinal  hernia  with  hj-drocele   349 

181.  Inguinal  hernia  invaginating  the  upper  portion  of  the  sac  of  a  hj^droccle  351 

182.  Tapping   a   hydrocele    351 

183.  First  step  in  operation  for  h\-drocele 352 

184.  Operation    for    hydrocele     352 

185.  Bilocular  hydrocele    353 

186.  Congenital    hydrocele    with   hernia    355 

187.  Inguinal  hernia  with  hydrocele  of   the   cord    357 

188.  Sac  of  chronic  hsematocele    359 

189.  Acute  gonorrhoeal  funiculitis    365 

190.  Lipoma  of  the  cord    366 

191.  Varicocele    367 

192.  A'aricocele  of   the   left   cord    367 

193.  Resection  of  spermatic  veins  through  an  inguinal  incision   369 

194.  Varicocele    operation    370 

195.  Bladder,  prostate,  seminal  vesicles,  and  vasa  def erentia    Z7Z 

196.  Right   seminal  vesicle,   posterior   surface,   dissected   out    374 

197.  Deferent  canal  and  seminal  vesicle  374 

198.  Sagittal  section  of  prostate  of  16-cm.  human  foetus  of  five  months   .......  381 

199.  Serial  cross-sections  of  prostate  from  apex  to  base    382 

200.  Plexus   of   vessels    surrounding   the    prostate    within    the    meshes    of    the 

false    capsule    383 

201.  Ejaculatory     ducts,     seminal     vesicles,     prostate,     membranous     urethra, 

Cowper's  glands,  bulbous  urethra,  corpora  cavernosa   385 

202.  Acute  catarrhal  prostatitis    387 

203.  Rectal    irrigator    389 

204.  Chronic    prostatitis    " 391 

205.  Secretion  from  case  of  chronic  infection  of  the  vesicles  and  prostate 392 

206.  Secretion    of    acute    prostatitis 393 

207.  Hypertrophy  of  median  lobe  of  the  prostate  397 

208.  Hypertrophy  of  the  left  lateral  and  median  lobes  of  the  prostate   398 

209.  Hypertrophy  of  the  median  and  one  lateral   lobe  of  the   prostate   399 

210.  Various   forms  of  hypertrophy  of  the   prostate    400 

211.  Glandular  hypertrophy  of  the  prostate   401 

212.  Prostatic  hypertrophy.     Acini  filled  with  desquamated  epithelial  cells  and 

corpora  amylacea   401 

213.  Hypertrophy   of   the   prostate.      Showing   acinus    surrounded    by   marked 

round-celled   infiltration    401 

214.  Prostatic    obstruction    with    hypertrophy    of    the    bladder-wall    and    con- 

traction  of  its   cavity    402 

215.  Prostatic  obstruction.      Effect  on  bladder  and  kidneys    403 

216.  Young's    prostatic    punch 414 

217.  Chetwood's  galvanocautery  prostatic  incisor   415 

218.  Suprapubic  prostatectomj-,  beginning  the  enucleation   417 

219.  Various  perineal  incisions 418 

220.  Showing   bifid    retractor,    exposing   and    making   tension    on    the    central 

tendon    419 

221.  Opening  of  urethra  on  sound,  preparatory-  to  introduction   of  tractor...  420 

222.  Young's  prostatic   tractor.      Closed    420 

223.  Young's  prostatic  tractor.      Opened    420 


XX  ILLUSTRATIONS 

224.  Tractor  in   position,   blades    separated,    prostate   pulled    down,    posterior 

surface  exposed.    Incisions  in  capsule  on  each  side  of  ejaculatory  ducts  421 

225.  External  enucleation  begun   422 

226.  Enucleation  of  lobes  422 

227.  Delivery  of   a   small  median   portion   into    lateral    cavity   by   the   use   of 

finger    instead   of   tractor    423 

228.  Delivery  of  median  portion  into  lateral  cavity   424 

229.  Division  of  lateral  w^all  of  urethra  to  allow  extraction  of  large  calculus 

through   lateral   cavity    425 

230.  Manner  of  introducing  of  double  tube  drain  into  bladder  and   packing 

into  bed  of  enucleated  prostate  in  perineal  prostatectomy 425 

231.  Carcinoma  of  the  prostate;  gross  specimen  and  microscopic  section 429 

232.  Carcinoma    of    the   prostate.      Arising   from    cellular    hyperplasia    of    the 

acini    430 

233.  Apparatus  for  suprapubic  drainage   431 

234.  Photomicrograph  of  sarcoma  of  the  prostate  (small  round  cell)   432 

235.  Psychrophore     443 

236.  Anastomosis,  between  the  vas  deferens  and  the  head  of  the  epididymis  453 

237.  Side   view   of   pelvic   viscera    466 

238.  Multiple  fused  bladder  469 

239.  Exstrophy   of  the  bladder    470 

240.  Day   urinal    (detachable    reservoir);    night    and     day     urinal    (detachable 

reservoir)     471 

241.  Excentric  trabecular  hypertrophy  of  the  bladder  474 

242.  Concentric  hypertrophy  of  the  bladder   475 

243.  Atomy  of  the  bladder,  with  dilatation   476 

244.  Interstitial  cystitis   491 

245.  Cystitis  cystica 492 

246.  Cystitis  cystica.     Photomicrograph  showing  cyst-formation  and  papillary 

outgrowth  of  mucosa   493 

247.  Pericystitis 501 

248.  Vesical  calcuH   508 

249.  Mulberry   calculus    509 

250.  Stone-searcher    512 

251.  Thompson's   stone-searcher    512 

252.  Large  vesical  calculus  513 

253.  Calculi  of  bladder  and  ureter   514 

254.  Vesical  calculi   517 

255.  Bigelow's  lithotrite    518 

256.  Weiss's  lithotrite    : 518 

257.  Jaws  of  Bigelow's  lithotrite   519 

258.  Bigelow's    evacuator   and   tubes    520 

259.  Opening  and   closing  the   blades   of   the   instrument   while   searching  for 

and  grasping  the  calculus   521 

260.  Crushing  a  small,  soft  calculus   521 

261.  Crushing  a  large,  hard  stone    522 

262.  Evacuating  fragments  after  the  calculus  has  been  crushed   522 

263.  Uric  acid   calculus   525 

264.  Uric  acid   calculus    526 

265.  Grooved  lithotomy  staff 529 

266.  Stone  forceps    (curved)    529 


ILLUSTRATIONS  xxi 

267.  Calculus   scoop    529 

268.  Vesical  calculus  almost  completely  filling  an  hypertrophied  bladder 534 

269.  Normal  relations.     Bladder  distended.     Bladder  and  rectum  distended...  536 

270.  Method  of  bladder  closure   537 

271.  Gibson's  method  of  closing  the  bladder  538 

212.   Gibson's  method  of  closing  the  bladder   539 

2T2).  Dawbarn's  method  of  suprapubic  bladder  drainage   540 

274.  Le   Fur's   case   of   foreign   body   in   bladder,   diagnosed   and   removed    by 

cystoscopy    541 

275.  Shoestring  incrusted  with  phosphates   542 

276.  Hair-pin    542 

277.  Hook  for  the  extraction  of  hair-pins  from  the  female  bladder 543 

278.  Myxosarcoma    545 

279.  Multiple    papillomata 546 

280.  Papilloma  of  the   bladder    547 

281.  Carcinoma  of  the  bladder   548 

282.  Cautery  resection   of  papilloma   of   the   bladder    553 

283.  Removal  of  large  amount  of  bladder  with  transplantation  of  ureter 554 

284.  Showing  method  of  closure  of  bladder  incision  555 

285.  Gushing  peritoneal  suture  closing  bladder  wound .   556 

286.  Colloidal  silver  radiogram,  showing  ureter  and  double  pelvis  on  left  side  ^62 

287.  Anomalous   ureters    563 

288.  Ureter  obstructed  at  its  emergence  from  pelvis  by  anomalous  vessels...    564 

289.  Vessel  divided,  fascia  stripped  away,  and  ureteropelvic  juncture   incised  564 

290.  Wound  sutured  transversely 565 

291.  Fascial  flap  sutured  over  ureteral  wound    565 

292.  End-in-side  anastomosis    567 

293.  End-in-side  anastomosis,  with  reinforcing  sutures   567 

294.  End-in-side   anastomosis    567 

295.  End-in-end  anastomosis   568 

296.  Oblique  end-to-end  anastomosis  569 

297.  Method  of  drawing  ureter  through  bladder-wall   570 

298.  Cross-section  of  anastomosis  complete    570 

299.  Operation   of   ureteroplasty   for   stricture    572 

300.  Ureteral  calculi   573 

301.  Multiple  calculi  of  the  ureter    574 

302.  Multiple  ureteral  calculi 575 

303.  Calculus  in  pelvic  ureter  576 

304.  Calculus  sacculated  in  wall  of  left  ureter   579 

305.  Muscle  splitting  incision  for  the  exposure  of  the  ureter   580 

306.  Longitudinal   section   of    right   kidney    586 

307.  Renal  pelvis  dissected  from  the  pyramids    586 

303.  Normal  kidney 588 

309.  Diagram  showing  location  of  nephrotomy  incision   589 

310.  Supernumerary  kidneys    589 

311.  Single  kidney  and  ureter  591 

312.  Horseshoe   kidney    591 

313.  Proper  method  of  applying  corset  for  movable  kidney   596 

314.  Lane-Curtis   abdominal   support    596 

315.  Rugh's  plaster  belt  for  nephroptosis   597 

316.  Edebohls's  position 598 


xxii  ILLUSTRATIONS 

317.  Lateroventral  lithotomy  position    599 

318.  Dissection  of  iliocostal  space,  exposing  the  superficial  muscles   600 

319.  Sustaining  sutures  for  fixing   the  kidney    601 

320.  Perirenal   extravasation   of  the   blood    603 

321.  Lateral  view,  showing  extent  of  transverse  incision  when  free  exposure 

is   needful    609 

2)21.  Exposure   of  the  kidney-  through  vertical   incision    610 

ZIZ.  Exposure  of  the  kidney-  611 

324.  Exposure  of  the  kidney  612 

325.  Nephrectomy   613 

326.  Nephrectomy-.      Pedicle   ligated   and  kidney   removed    613 

327.  Nephrectomy-.     Vein  and  artery  held  apart  for  separate  ligation 614« 

328.  Incision  of  the  parietal  peritoneum  to  outer  border  of  colon  in  transperitoneal 

nephrectomy   614 

329.  Subcapsular  nephrectomy    615 

330.  Nephrolithiasis    618* 

331.  Various  forms  of  kidney-stone,  illustrating  the  irregularities  in  shape...   620 

332.  Multiple  bilateral  renal  cj'Sts  and  calculi  621 

ZZZ.  Multiple  branched  calculi  of  the  kidney   623 

334.  Multiple  renal  calculi   624 

335.  Calculus  impacted  in  the  pelvic  end  of  the  ureter 625 

336.  The  proper  position  for  the  incision 629 

2)2)7 .  Lateral  view  of  kidnej-    630 

338. "Method  of  suturing  split  kidnej^   631 

339.  Pyonephrosis    634 

340.  Operation   of    nephrotomy    637 

341.  Watson's  nephrostoni}-  apparatus   638 

342.  Operation  of  nephrostomy.     First  step   639 

343.  Operation  of  nephrostom3^     Second  step   640 

344.  Pyelonephritis 641 

345.  Acute  haematogenous  suppurative  nephritis    644 

346.  Advanced  tuberculosis  of  the  kidne}'  653 

347.  Tuberculosis  of  the  kidney .  655 

348.  Congenital  bilateral  hydronephrosis    661 

349.  Destruction  of  kidne}-  from  hydronephrosis    663 

350.  Hydronephrosis,  illustrating  mild  grade  of  the  condition 665 

351.  Huge  hydronephrosis.     Its  position,  outhne,  and  approximate  size  clearly 

demonstrated  by  colloidal  silver .   665 

352.  Double  hydronephrosis  secondary  to  concentric  hypertrophy  of  bladder, 

this  being  secondary  to  hypertrophy  of  the  prostate  and  calcuhis 665 

353.  Hydronephrosis  from  kinked  ureter,  caused  by  anomalous  blood-vessels  666 

354.  Blood-vessels   cut  and   tied.      Fatty  fascial   flap   raised   and   ureteropelvic 

juncture   divided    ggg 

355.  Plastic  operation  on  uteropelvic  juncture  completed    666 

356.  Fatty  fascial  flap  in  position  and  held  by  a  few  catgut  sutures 666 


357.  Mesothelioma 


670 


358.  Mixed  tumor  of  childhood   572 

359.  Mixed  tumor  of  kidney   g7j 

360.  Sarcoma  of  kidney 572 

361.  Photomicrograph  of  section  from  sarcoma  of  kidney   673 


ILLUSTRATIONS  xxill 

362.  Carcinoma  of  the  kidney    674 

363.  Carcinoma  of   the  kidney    675 

364.  Papillo-adenocarcinoma    676 

365.  Colloidal  silver  injection  shows  renal  pelvis  to  be  constricted,  its  calyces 

either  irregularly  distended  or  elongated  and  narrowed    678 

366.  Polycystic    degeneration    of   kidney    680 

367.  Hypernephroma  of  suprarenal  gland   685 

368.  Chancre  of  the  reflected  layer  693 

369.  Chancre  of  the  meatus   693 

370.  Chancre  of  the  coronary  sulcus   694 

^^\  I      Chancre  of  the   lip 704 

2)72i.  Chancre  of  the  tongue  706 

374.  Chancre  of  the  tongue 707 

375.  Chancre  of  finger.     Nine  weeks'  duration  709 

376.  Erythematous  syphilide 722 

2)77.  Flat  papular  syphilide 723 

378.  Acuminated  papular  syphilide   724 

379.  Acuminated  papular  syphilide   725 

380.  Large   flat   papular   syphilide    '. .  726 

381.  Large  fiat  papular  syphilide    727 

382.  Large  flat  papular  syphilide    728 

383.  Large  flat  papular  syphilide,  showing  scaling   729 

384.  Mucous  patches  of  the  lips  730 

385.  Mucous  patches  about  the  anus  730 

386.  Vegetations  and  mucous  patches  about  the  vulva  730 

387.  Papular  syphilide,  showing  papillary  overgrowth    . 731 

388.  Syphilitic    vegetations     732 

389.  Papulo-squamous    syphilide 7^21 

390.  Gummata  of  cheek  and  nose  734 

391.  Papulo-squamous    syphilide    735 

392.  Papulo-squamous  of  the  hand 735 

393.  Large  pustular  syphilide 738 

394.  Pustular  syphilide  (pustulo-crustaceous)   740 

395.  ") 

_„ ,'  V    Pustular   syphilide    (pustulo-crustaceous)    741 

396.  j 

397.  Pustular  syphilide    742 

398.  Flat   pustular   and  papulo-squamous   syphilide 743 

399.  Large,  flat  pustular  syphilide  744 

400.  Serpiginous  syphilide    744 

401.  Non-ulcerating  tubercular  syphilide    745 

402.  Non-ulcerating    tubercular    syphilide    746 

403.  Tubercular    (squamous)    syphilide    746 

404.  Tubercular    syphilide    747 

405.  Tubercular    syphilide 748 

406.  Syphilitic  rupia  following  the  bullous  syphilide    751 

407.  Gummatous  syphilide   752 

408.  Single  ulcerating  gumma    753 

409.  Ulcerating  gummata  becoming  confluent   /. .  753 

410.  Multiple  gummata  of  the  leg  754 

411.  Sloughing  gumma  of  the  leg   755 


xxiv  ILLUSTRATIONS 

412.  Ulcerating  gummata  of  the  malleolar  region 756 

413.  Syphilitic  alopecia  following  ulcerative  lesions 757 

414.  Gummatous  ulceration  destroying  the  nose 798 

415.  Gummatous  osteomyelitis  of  femur 804 

416.  Skull  showing  the  results  of  gummatous  osteoperiosteitis 805 

417.  Vault  of  cranium  exhibiting  the  results   of  gummatous   osteoperiosteitis....  806 

418.  Rarefying  gummatous  osteitis  of  ulna .- 807 

419.  Tubercular  and  gummatous  ulceration  of  hereditary  syphilis   832 

420.  Syphilitic  dactylitis    833 

421.  Hereditary  syphilis.     Cicatrices  of  fissured  lips  and  gummata  of  the  fore- 

head and  orbit    834 

422.  Showing  paraphernalia  for  preparation  of  salvarsan  or  neosalvarsan  ....   872 

423.  Arrangements  for  administration  of  salvarsan  or  neosalvarsan 873 

424.  Intramuscular  injection  of  mercury 881 

COLORED  PLATES 

PLATE  PAGE 

I.  Inorganic  urinary  sediment Frontispiece 

II.  A.  Pus  of  acute  gonorrhoea.  B.  Pus  of  "pyogenic"  urethritis.  C.  Pus  of 
acute  gonorrhoea,  with  mixed  infection.  D.  Pus  of  acute  "pyogenic" 
urethritis , 19 

III.  A.  Pus  of  subacute  gonorrhoea  with  mixed  infection.    B.  Shred  of  gleet 19 

IV.  A.  Diverticulum   of  urethra.     B.  Chronic  urethritis.     C.  Normal  anterior 

urethra.  D.  Normal  verumontanum.  E.  Papilloma  of  urethra.  F.  Gran- 
ular patch  of  chronic  urethritis.  G.  Enlarged  verumontanum,  display- 
ing utriculus  on  summit,  preceded  by  orifices  of  ejaculatory  ducts. 
H.  Cicatrization  in  chronic  granular  urethritis.     I.  Stricture  of  anterior 

urethra 33 

V.  A.  Anterior  bladder- wall,  with  air  bubble.  B.  Normal  ureteral  orifice. 
C.  Trabeculation  of  the  bladder.  D.  Indigocarmin  coming  from  ureter. 
E.  Double  ureteral  orifice  of  bifurcated  ureter.  F.  Shell  of  inspissated  pus 
surmounting  ureteral  orifice  (case  of  pyonephrosis) .  G.  Catheter  entering 
normal  ureter.  H.  Cystitis  cystica.  I.  Ulcerating  gumma  (Engel- 
mann).  J.  Bullous  oedema  of  vesical  trigone  (Rumpel).  K.  Tuber- 
culous ureteral  orifice  (case  of  renal  tuberculosis).    L.  Vesical  calculi.  ...     48 

VI.  A.  Chancroids  of  the  prepuce.    B.  Epithelioma  of  glans 114 

VII.  Multiple  chancroids  (Fox) 116 

VIII.  Showing  the  relations  and  coverings  of  the  testicle  and  epididymis  (Testut) .  .   298 
IX.  Position  and  relation  of  the  kidneys  and  other  retroperitoneal  structures. .  .  .   584 

X.  Tuberculosis  of  the  kidney 652 

XI.  Mesothelioma 670 

XII.  Chancre  on  shaft  of  penis 694 

XIII.  Chancre  of  the  corona  (Fox) 698 

XIV.  Chancre  of  Hp 704 

XV.  Papulo-squamous  syphilide 734 

XVI.  Papulo-squamous  syphilide  of  the  hand 734 

XVII.  Pustulo-crustaceous  syphilid^  (Fox) 740 

XVIII.  Ulcerating  tubercular  syphilide 748 

XIX.  Graphic  portrayal  of  the  "Wassermann  reaction,"  demonstrating  the  results 

(1)  in  the  case  to  be  tested,  (2)  the  positive  and  (3)  the  negative  control. .  852 

XX.  Spirocheta  pallida 856 

XXI.  Luetin  cutaneous  reaction 856 


GENITOURINARY  SURGERY 
AND  VENEREAL  DISEASES 


CHAPTER  I 
EXAMINATION  OF  THE  PATIENT 

Since  examination  of  a  patient  is  conducted  for  the  purpose  of  so  directing 
his  treatment  that  he  shall  be  completely  restored  to  health,  it  is  obvious  that 
this  purpose  often  will  not  be  attained  unless  in  addition  to  detecting  gross 
abnormalities  the  examiner  makes  a  further  search  for  all  other  conditions  which 
may  have  a  bearing  upon  the  development  and  course  of  his  major  lesion,  may 
influence  its  treatment,  or  may  persist  as  troublesome  or  devitalizing  agencies 
after  the  major  lesion  has  been  cured.  If,  for  instance,  a  patient  be  suffering 
from  a  chronic  gonococcic  urethritis,  as  shown  by  a  urethral  discharge  con- 
taining gonococci  complicated  by  swelling  of  the  knee-joint,  the  cure  of  neither 
the  major  ailment  nor  its  complication  will  necessarily  be  effected  if  there  be 
an  unrecognized  accompanying  oxaluria,  chronic  follicular  tonsillitis  or  colonic 
stasis.  It  follows  that  the  percentage  of  cures  will  be  higher  when  such  affec- 
tions are  treated  by  practitioners  who  make  a  thorough  examination  a  matter 
of  routine. 

This  examination  should  include  a  brief  family  history,  the  pre\'ious  medical 
and  surgical  history  of  the  patient  with  especial  reference  to  affections  of  the 
genito-urinary  organs,  a  history  of  the  complaint  for  which  the  patient  seeks 
professional  help,  particularly  in  regard  to  its  cause,  onset,  progress,  and  effect 
on  the  general  health,  and  a  general  and  local  examination,  supplemented,  when 
needed,  by  laboratory  methods.  The  following  are  given  as  suggestive  headings 
for  such  a  history: 

1.  Name,  residence,  occupation,  nativity,  age,  social  condition. 

2.  Chief  Complaint. — Effect  on  mode  of  living. 

3.  Family  History. — Health  of  parents,  sisters,  brothers,  and  nearest  rela- 
tives. If  some  or  all  be  dead,  the  causes  therefor,  and  the  ages  at  which  death 
occurred.  Tuberculosis  (cough,  limp,  crooked  back,  dead  bone).  Syphilis 
(stillbirths  or  hea\y  infant  mortality,  aneurism,  progressive  paralysis,  locomotor 
ataxia).    Diabetes.    Haemophilia.    Tumors.    IMalformations. 

4.  Previous  Medical  History. — Mode  of  life.  General  condition  of  health, 
strength,  endurance,  digestion,  and  sleep.  Condition-  of  bowels.  Acute  infectious 
diseases  with  sequelje,  if  there  have  been  such.  Cough.  Surgical  operations. 
Affections  of  bones  or  joints.  Trouble  with  eyes  or  ears.  Disturbances  of  the 
nen,'Ous  system. 

1 


2  GENITO-URINARY  SURGERY 

5.  Sexual  History. —  (a)  Temperament,  (b)  Age  of  beginning  masturba- 
tion. Frequency  of  the  act  and  time  of  its  discontinuance.  The  effect  of  the 
latter  upon  nocturnal  pollutions,  (c)  Frequency  and  normality  of  coitus, 
(d)  Frequency  and  vigor  of  erection.  Promptness  of  emission.  Immediate 
effect  upon  erection  of  emission.  In  women  the  onset  and  character  of 
menstruation. 

6.  Venereal  History. — Urethral  discharge.  Sores  upon  the  external  gen- 
itals or  elsewhere  lasting  more  than  a  few  days,  skin  eruptions,  sore  throat. 

7.  Previous  Urological  History. — Late  bed-wetting.  Nocturnal  or  diurnal 
incontinence.  Frequancy  of  urination.  Force,  volume  and  steadiness  of 
stream.  Promptness  and  ease  of  beginning  the  act.  Sharpness  of  cut  off. 
Total  quantity  passed  in  twenty-four  hours.  Immediate  effect  of  ingestion  of 
fluids.  Average  quantity  passed  with  each  act  of  micturition.  Retention  of 
urine.     Passage  of  blood  or  calculi.     Instrumentation. 

8.  History  of  Present  Ailment. — A  brief  statement,  from  the  patient's 
standpoint,  of  the  cause,  onset,  progress  and  chief  symptoms  of  the  condition  for 
which  the  surgeon  is  consulted.  Amount  of  weight  lost;  rapidity  of  loss  and 
impairment  of  bodily  and  mental  vigor  and  endurance. 

CLINICAL  AND  LABORATORY  EXAMINATION. 

I.  General  Observations. — Height.  Weight.  Color  (jaundice,  pallor, 
pigmentation,  etc.).  Temperature  (if  fever,  its  type  and  variation).  Pulse  (fre- 
quency, tension,  volume,  rhythm,  and  the  effect  upon  it  of  active  exercise). 
Blood-pressure.  Respiration  (rate  and  character).  Condition  of  superficial 
arteries  and  veins  (sclerosis,  pulsation,  etc.).  Muscular  tonus.  Eruptions  or 
their  scars.     Superficial  lymphatic  glands.     (Edema.     Malformations. 

II.  Regional  Examinations. — Head. — Alopecia,  complexion,  expression, 
etc.     Conformation.     Irregularities  of  the  bony  surface. 

Eyes:  Evidences  of  present  or  past  inflammation.  Corneal  opacities. 
Muscular  insufficiency  or  paralysis.  Pupils,  abnormality  in  conformation  or 
reaction.     Acuity  of  vision.     Retinoscopy,  where  indicated. 

Nose:     Deformity,   rhinitis,   ulceration,    necrosis. 

Ears:    Functional  perfection,  evidences  of  present  or  past  inflammation. 

Mouth:  Scars.  Ulceration.  Functional  potentiality  of  the  teeth  and  their 
condition.  Gums.  Tonsils.  Pharynx.  Larynx  and  vocal  cords  when  symp- 
toms indicate  such  an  examination. 

Neck. — Freedom  of  motion.    Lymph-nodes.    Thyroid. 

Thorax.- — Conformation  and  development,  degree  and  symmetry  of  expansion 
and  type  of  respiration  (costal,  abdominal). 

Lungs:   Palpation,  percussion,  auscultation  (anteriorly  and  posteriorly). 

Heart:  Outline,  apex  beat,  character  of  sounds  (murmur, •friction,  thrill,  etc.) 

Abdomen. — Inspection.  Conformation  (fat,  thin,  retracted,  sagging).  Mus- 
culature. Venous  circulation  (if  visible).  Peristalsis.  Hernia.  Palpation 
(rigidity,  contained  organs,  fluid,  tumors,  palpable  masses,  peristalsis).  Per- 
cussion (position  of  viscera,  tumor,  fluid).    Auscultation  (peristalsis,  friction). 

An  examination  as  comprehensive  as  that  indicated  above  is  usually  not 
undertaken,   because,   until   within   recent  years,   the  realm   of  genito-urinary 


EXAMINATION  OF  THE  PATIENT  3 

surgery  has  been  dominated  by  the  venereal  affections,  many  of  which,  as  they 
are  presented  to  the  surgeon,  occur  in  otherwise  healthy  young  men,  are 
easily  recognized,  and  make  a  prompt  convalescence,  providing  the  treatment 
be  not  too  meddlesome.  With  a  broader  appreciation  of  the  factors  which  are 
operative  in  causing  pathological  conditions  of  the  kidney,  for  instance,  and 
some  knowledge  of  the  role  played  by  gastro-intestinal  toxaemia,  by  an  over- 
functioning  thyroid,  by  cardiovascular  disturbances  and  degenerations,  and  by 
foci  of  infection,  the  value  of  a  searching  examination  in  at  least  a  certain  pro- 
portion of  cases  presenting  themselves  for  treatment  is  obvious.  With  the  grow- 
ing efficiency  of  laboratory  methods  there  is  a  tendency  to  somewhat  minimize 
the  importance  of  the  older  methods  which  are  summarized  under  the  heading 
''  Inspection  and  Palpation."  Either  may  be  the  diagnostic  means  at  our  disposal. 
The  methods  applicable  to  the  particular  region  under  investigation  are 
described  under  the  headings  of  the  various  organs  involved.  In  view  of  the 
protean  symptomatology  of  tabes,  an  investigation  of  the  reflexes  whose  con- 
dition establishes  its  diagnosis  of  cardinal  importance  to  the  surgeon,  and  should 
be  made  in  practically  every  case  on  which  he  intends  to  operate. 

EXAMINATION  OF  THE  GENITO-URINARY  SYSTEM 

Clinical  Examination. — Inspection  and  palpation  of  abdomen,  loins,  in- 
guinal regions  and  external  genitalia  for  enlargements,  misplacements,  alterations 
in  density  or  congenital  deformities. 

Palpation  of  the  prostate,  seminal  vesicles  and  the  ampullae  of  the  vasa;  in 
women  palpation  of  the  uterus,  tubes,  and  ovaries. 

Inspection  of  the  urine  voided  in  at  least  two  portions  in  the  presence, 
preferably  in  the  sight,  of  the  examiner  that  he  may  observe  the  size,  form, 
continuity,  and  force  of  the  stream  as  well  as  the  appearance  of  the  secretion 
itself,  whether  clear,  cloudy,  bloody  or  studded  with  shreds,  together  with  the 
distribution  of  the  abnormal  elements  in  the  different  portions. 

Instrumental  Examination. — Of  the  urethra,  to  determine  its  length, 
calibre  (and  variations  thereof  with  their  location),  and  the  appearance  of  its 
mucosa,  made  by  means  of  catheter,  urethrometer,  bougie,  and  urethroscope. 

Of  the  bladder,  to  determine  its  capacity,  irritability,  ability  to  completely 
empty  itself,  and  the  presence  or  absence  of  foreign  bodies  and  intravesical 
lesions,  made  by  means  of  catheter  and  irrigator,  vesical  sound,  and  cystoscope. 

Of  the  ureters  and  kidneys,  to  determine  their  number,  position,  size,  con- 
formation, the  presence  or  absence  of  stone,  and,  when  needful,  their  individual 
function,  made  by  means  of  the  cystoscope,  ureteral  catheter,  injection  of 
certain  dyes  and  drugs,  and  the  X-ray. 

The  determination  of  the  amount  of  urine  secreted  in  the  course  of  the 
twenty-four  hours  is  an  important  part  of  the  clinical  examination,  though 
obviously  it  cannot  be  ascertained  in  the  office  or  operating  room. 

Laboratory  Examination. — Urinalysis. 

Completion  of  tests  for  the  determination  of  kidney  function  begun  in  the 
operating  room,  ward,  etc. 

Examination  of  normal  and  pathological  secretions  by  means  of  smears, 
inoculation  of  culture  media,  and  by  animal  inoculations. 
.  Examination  of  the  blood,  microscopical  and  serological. 


4  GENITO-URINARY  SURGERY 

CARDINAL  SYMPTOMS  AND  SIGNS 

There  are  a  few  cardinal  symptoms  and  signs  so  commonly  the  exponents 
of  lesions  of  the  urological  system  that  a  special  study  of  their  expression  seems 
needful.  These  are  pain,  haematuria,  pyuria,  frequency  of  urination,  alterations 
in  the  stream,  suppression  of  urine,  retention  of  urine,  and  incontinence  of 
urine.    To  the  last  three  is  given  separate  consideration  in  Chapter  VI. 

Pain. — Pain  symptomatic  of  pathological  conditions  of  the  urinary  tract 
is  subject  to  so  many  variations  in  degree,  is  so  often  referred  to  regions  other 
than  the  seat  of  disease^  and  is  so  affected  by  vesical  tension  and  by  micturition, 
that  a  serviceable  classification  of  the  manifestations  of  this  symptom  is  difficult. 
Perhaps  the  subject  may  be  best  considered  under  the  following  heads: 

1.  The  character  and  intensity  of  pain. 

2.  The  region  of  pain. 

3.  The  relation  of  pain  to  the  act  of  micturition. 

The  Character  and  Intensity  of  Pain. — Pain  symptomatic  of  urinary 
affections  may  vary  from  an  apparent  muscular  stiffness  comparable  to  that  fol- 
lowing active  exertion,  and  noticed  only  on  movement,  or  a  dull  ache  readily 
forgotten  when  the  mind  is  employed,  to  a  severe  pain  distracting  the  attention 
and  seriously  interfering  with  the  business  of  life,  or  to  an  unbearable  anguish 
producing  vomiting,  syncope,  and  sometimes  death. 

The  pain  may  be  aching  and  rheumatoid,  as  in  renal  congestion,  may  be 
burning,  as  in  cases  of  prostatocystitis,  may  be  shooting  and  lancinating,  as  in 
vesical  neuralgia,  or  may  be  tearing  and  griping,  as  in  renal  colic. 

It  may  be  steady,  as  in  vesical  carcinoma,  it  may  be  intermittent,  as  in 
bladder  stone,  or  it  may  be  continuous  with  violent  exacerbations,  as  in  calculous 
pyelitis  or  acute  hydronephrosis.  If  the  suffering  incident  to  acute  blocking 
of  the  ureter  be  excepted,  most  of  the  pain  of  urinary  disease  comes  from  the 
bladder  and  prostatic  urethra. 

Diseases  of  the  kidney  and  its  pelvis  are  comparatively  painless,  provided 
there  is  free  drainage  through  the  ureter.  A  calculous  pyelitis  may  last  for 
years  with  no  symptoms  other  than  backache,  aggravated  on  motion,  or  there 
may  be  frequent  paroxysms  of  agonizing  pain,  and  indeed  this  may  occur  in 
pyelitis  without  calculi.  These  paroxysms  are  due  to  acute  retention^  caused 
by  valvular  formation,  plugging  of  the  ureter  by  pus  or  blood,  or  blocking  of 
it  by  calculus. 

Inflammation  of  the  ureters  in  itself  occasions  no  pain  which  can  be  recog- 
nized as  characteristic.  It  is,  however,  so  frequently  complicated  by  partial  or 
complete  stoppage,  with  consequent  tension  of  the  kidney  capsule,  that  patients 
suffering  from  this  form  of  inflammation  are  subject  to  violent  attacks  of  colic. 
The  absolutely  unbearable  pain  of  a  kidney  stone  passing  along  the  ureter  is 
probably  due  more  to  spasmodic  mechanical  blockage  of  this  canal  and  con- 
sequent retention  of  urine  in  the  kidney .  pelvis  than  to  mechanical  erosions 
caused  by  the  passage  of  an  irregular  foreign  body.  This  hypothesis  would  seem 
to  be  confirmed  by  the  comparative  painlessness  of  ureteral  catheterizations. 

The  pain  of  bladder  disease,  aside  from  that  caused  by  muscular  contraction 
incident  to  micturition,  is  proportionate  to  the  intensity  of  the  pathological 


EXAMINATION  OF  THE  PATIENT  5 

process.    Chronic  cystitis  causes  very  little  pain.    Acute  cystitis  and  acute  reten- 
tion are  extremely  painful. 

The  suffering  incident  to  inflammation  or  erosion  due  to  a  calculus  or  a 
foreign  body  varies  greatly.  In  general,  large  smooth  calculi  are  less  painful 
than  those  which  are  small  and  irregular.  Malignant  growth  of  the  bladder  may 
be  absolutely  painless  until  it  becomes  complicated  by  cystitis  or  infiltrates  the 
muscular  walls.  Even  under  these  circumstances  pain  may  be  slight  or  bearable. 
It  is  often,  however,  constant,  subject  to  spasmodic  exacerbations,  and  more 
intense  and  wearing  than  any  other  form  of  vesical  pain  except  that  due  to 
retention. 

Tuberculous  ulceration  may  be  painless,  except  during  and  after  micturition. 
When  the  lesions  are  situated  in  the  trigonum  they  may  cause  constant  burning 
wearing  pain,  with  reflexes  to  the  rectum,  anus,  perineum,  and  inner  surfaces 
of  the  thighs. 

The  Region  of  Pain. — Pain  is  generally  felt  in  the  region  involved.  Thus, 
in  acute  hydronephrosis  or  chronic  pyelitis  the  pain  is  constantly  referred  to  the 
region  of  the  kidney,  though  reflexes  may  be  so  pronounced  as  to  make  this 
fact  apparent  only  after  careful  questioning  of  the  patient.  Inflammation  of  the 
bladder  usually  causes  pain  directly  in  the  vesical  region. 

Sometimes  no  pain  is  experienced  at  the  seat  of  lesion,  the  abnormal  sensation 
being  referred  to  the  distribution  of  anastomosing  nerve-trunks  or  to  the  terminal 
extremities  of  the  nerve  irritated.  Thus,  disease  of  the  kidneys  constantly  gives 
rise  to  pain  which  is  felt  chiefly  in  the  groin,  down  the  thigh,  or  in  the  testicle. 
The  irritation  caused  by  stone  in  the  bladder  produces  urethral  pain,  felt  a  short 
distance  back  from  the  meatus.  Inflammation  of  the  trigonum  frequently  causes 
Itching,  tickling,  and  painful  spasm  of  the  anal  sphincter. 

Occasionally  the  healthy  bladder  may  be  the  seat  of  almost  unbearable  pain, 
due  entirely  to  inflammation  of  the  kidney  pelvis.  As  a  rule,  lesions  coniined 
to  the  upper  half  of  the  ureter  produce  renal  symptoms,  while  those  in  the  lower 
half  give  rise  to  vesical  irritability,  etc. 

The  pain  of  kidney  disease  of  one  side  may  be  referred  to  the  opposite  healthy 
side,  or  to  the  shoulder,  the  groin,  the  urethra,  the  testicle,  the  inner  surface  of 
the  thigh,  the  calf,  or  the  heel.  (This  pain  in  the  heel  is  also  a  reflex  from  the 
prostatic  urethra.) 

Pain  of  bladder  trouble  may  be  referred  to  the  suprapubic  region,  the  sacral 
or  lower  lumbar  vertebrae,  the  glandular  urethra,  the  kidneys,  the  perineum  and 
anus,  the  inner  surface  of  the  thigh,  and  the  sole  of  the  foot.  All  these  trans- 
ferred pains  may  be  symptoms  of  inflammation  of  the  prostatic  urethra. 

Diffuse  suprapubic  pain  generally  indicates  disease  posterior  to  the  vesical 
sphincter.  If  constant,  it  suggests  advanced  vesical  atony,  vesical  carcinoma, 
severe  chronic  cystitis,  perivesical  abscess  or  inflammation,  and  rarely  ureteral 
disease.  If  transient  in  duration  and  provoked  by  micturition,  it  suggests  prosta- 
tic enlargement  with  residual  urine.  _  When  increased  by  micturition,  it  generally 
means  vesical  tenesmus  in  a  partially  atonic  bladder.  The  transient  suprapubic 
pains  of  all  grades  of  cystitis,  tuberculosis,  and  ulceration  of  the  bladder  and 
of  chronic  prostatic  inflammation  are  relieved  by  micturition. 

Perineal  pain  always  signifies  disease  of  som.e  structure  in  intimate  relation 


6  GENITO-URINARY  SURGERY 

with  the  bladder  neck  or  base,  or  of  the  prostatic  or  membranous  urethra.  If 
constant,  chronic  prostatitis,  beginning  prostatic  hypertrophy,  carcinoma,  and 
encysted  calculi  are  suggested.  If  transient  and  relieved  by  micturition,  acute 
inflammation  and  tuberculous  disease  of  the  prostate  or  vesical  trigone  must  be 
considered.  When  increased  by  micturition,  it  suggests  either  inflammation 
posterior  to  the  vesical  trigone,  such  as  might  be  caused  by  calculi  ■  pouched 
behind  an  enlarged  prostate,  or  tuberculous  infiltration,  or  involvement  of  the 
bulbous  or  membranous  urethra,  such  as  would  result  from  sub-urethral  abscess, 
or  inflamed  stricture,  carcinoma,  or — rarely — tuberculosis. 

Pain  referred  to  the  glans  penis,  whether  constant  or  occurring  only  at  the 
beginning  or  during  the  act  of  micturition,  always  implies  disease  of  some  part 
of  the  urethra  or  the  prostate.  If  constant,  prostatorrhoea,  chronic  inflammation 
of  the  prostatic  urethra,  or  beginning  enlargement  of  the  prostate  gland  is  indi- 
cated. If  occurring  just  before  micturition,  urethral  obstruction  either  from 
clot  retention,  calculous  impaction,  or  senile  prostatic  enlargement  is  present. 
If  present  throughout  micturition,  it  may  be  due  to  some  local  lesion  in  the 
urethra;  either  inflammation,  a  granular  patch,  ulceration,  neoplasm,  or  a 
narrow  meatus.  If  present  only  at  the  end  of  micturition,  it  may  be  due  to  a 
pathological  condition  at  or  near  the  internal  (vesical)  orifice  of  the  urethra, 
such  as  severe  prostatic  inflammation  or  congestion,  vesical  tumors  impinging 
on  the  internal  urethral  orifice,  inflammation  of  the  trigone,  ulceration  of  the 
posterior  or  lateral  walls  of  the  bladder,  any  form  of  acute  localized  inflammation 
in  any  part  of  the  bladder  causing  spasm  involving  the  neck,  vesical  calculus, 
or  the  vesical  spasm  of  renal  colic. 

Chronic  inflammation  of  the  prostate  is  usually  characterized  by  a  more  or 
less  constant  pain  referred  to  the  sacrum.  In  seminal  vesiculitis  this  pain  iS 
referred  to  the  hip-joint.  In  nephritis  or  pyelitis  it  is  referred  to  a  point  just 
below  the  last  rib  to  the  outer  side  of  the  erecta  spinse  muscle  and  is  not  affected 
by  the  act  of  micturition. 

The  Relation  of  Pain  to  the  Act  of  Micturition. — Pain  may  be  experi- 
enced before,  during,  or  at  the  completion  of  the  act  of  micturition. 

Pain  preceding  micturition  is  due  to  a  hyperaesthetic  condition  of  the  vesical 
mucosa  or  the  prostatic  urethra.  This  hypersesthesia  may  be  caused  by  various 
neuroses,  by  congestion,  or  by  inflammation, — the  tension  of  the  full  bladder 
causing  distress.  If  the  urine  is  strongly  acid  or  concentrated,  as  in  cases  of 
rheumatism,  gout,  or  acute  fevers,  even  the  healthy  mucosa  may  be  irritated, 
and  may  be  the  seat  of  burning  or  discomfort,  relieved  by  emptying  the  bladder. 
Exceptionally  pain  before  urinating  is  a  symptom  of  disease  of  the  kidney  pelvis. 

Micturition  pain  is  also  occasioned  by  irritable  or  inflammatory  conditions 
of  the  bladder  or  prostate,  since  the  muscular  contraction  required  to  expel  urine 
necessarily  disturbs  the  hypersensitive  tissues.  Ulceration  or  inflammation  of 
the  vesical  neck  is  particularly  liable  to  cause  urination  pain.  The  sensation 
may  be  aching,  burning,  shooting  and  darting,  or  distinctly  neuralgic  in  type. 

Pain  after  urination,  generally  considered  characteristic  of  stone,  may  be 
caused  by  any  inflammatory  or  ulcerative  condition  of  the  bladder  neck.  In 
many  cases  it  is  probably  due  to  fissure  or  erosion,  and  is  comparable  to  the  pain 
felt  after  defecation  in  cases  of  anal  fissure.     The  probability  that  this  is  the 


EXAMINATION  OF  THE  PATIENT  7 

cause  of  the  severe  forms  of  suffering  is  still  further  increased  by  the  fact  that  it 
is  commonly  associated  with  tenesmus  and  involuntary  contraction  of  all  the 
perineal  muscles,  and  that  it  is  relieved  by  local  applications. 

When  pain  at  the  end  of  urination  is  greatly  increased  by  exercise  or  jolting, 
and  is  relieved  by  rest  in  bed  and  by  urination  in  the  dorsal  decubitus,  it  is 
probably  due  to  calculus  or  to  foreign  body.  The  pain  at  the  end  of  micturition 
caused  by  tuberculous  ulceration  at  the  neck  of  the  bladder,  or  exceptionally  by 
cystitis,  may  also  be  relieved  by  rest  and  be  aggravated  by  motion,  but  not  to 
the  same  extent  as  is  observed  in  calculus. 

Aside  from  pain  due  to  distinct  lesions  of  the  urinary  tract,  there  is  appar- 
ently a  pure  neurosis  characterized  by  continuous  or  intermittent  pain  amounting 
sometimes  to  veritable  anguish  felt  in  the  bladder,  suprapubic  region,  or 
perineum,  by  frequent  urination,  and,  unless  the  desire  to  empty  the  bladder  is 
at  once  gratified,  by  incontinence.  There  is  usually  nocturnal  remission,  the 
patient  sleeping  soundly  for  several  hours.  The  symptoms  vary  in  intensity; 
active  pursuits,  either  of  mind  or  of  body,  cause  marked  temporary  amelioration. 

Exploration  proves  the  urethra  and  bladder  to  be  exquisitely  sensitive.  This 
condition  is  termed  irritable  or  neuralgic  bladder,  and  is  sometimes  a  symptom 
or  prodrome  of  tabes,  though  it  is  more  commonly  a  reflex  from  the  rectum,  anus, 
or  generative  organs.  It  has  been  observed  in  association  with  influenza,  rheu- 
matism, gout,  and  malaria. 

H.EMATURiA. — The  vascularity  of  the  urinary  tract  and  the  readiness  with 
which  it  becomes  engorged  are  reasons  why  blood  is  so  often  found  mixed  with 
the  urine,  and  why  it  may  be  profuse  from  apparently  slight  causes. 

The  color  of  the  urine  is  not  an  absolute  proof  of  the  presence  of  blood,  since 
an  excess  of  uric  acid  or  of  bile-pigment,  or  the  ingestion  of  senna,  rhubarb,  or 
carbolic  acid,  or  the  presence  of  haemoglobin,  gives  a  similar  reddish  or  brownish 
tint.  The  diagnosis  must  therefore  be  founded  on  a  microscopic,  spectroscopic, 
or  chemical  examination  (see  p.  18).  In  cases  of  pyelitis  and  cystitis  the  blood 
may  be  found  irregularly  mixed  with  the  purulent  deposit,  imparting  none  of  its 
color  to  the  supernatant  liquid. 

Clots  may  be  dark  red  and  readily  broken  up,  or  tough  and  yellowish  red, 
suggesting  the  appearance  of  organized  tissue.  A  microscopic  examination  is 
required  to  distinguish  these  fibrinous  clots  from  fragments  of  neoplasm. 

A  long,  thin,  rounded  clot  in  the  shape  of  a  small  earthworm  must  necessarily 
have  been  moulded  in  the  ureter,  and  hence  indicates  either  renal  or  ureteric 
origin  of  bleeding.  Short  cylindrical  clots  have  not  the  same  significance,  since 
they  may  have  been  formed  in  the  urethra. 

Since  congestion  is  so  important  a  predisposing  condition  to  haematuria,  it 
sometimes  happens  that  symptoms  of  this  engorgement  precede  hemorrhage. 
There  may  be  a  sensation  of  weight  and  discom.fort  rather  than  actual  suffering, 
or  an  attack  of  kidney  colic.  These  pains  are  of  brief  duration,  are  felt  in  the 
region  of  the  kidneys  or  along  the  ureters,  and  strongly  point  to  the  renal  origin 
of  bleeding.    Such  premonitory  pains  are  rarely  felt  in  bleeding  from  the  bladder. 

Blood  which  appears  with  the  first  jet  of  urine  (initial  haematuria),  the 
remainder  of  the  liquid  remaining  clear,  must  necessarily  come  from  some  portion 
of  the  urethra.    In  this  case  the  quantity  of  blood  must  be  very  slight,  otherwise 


8  GENITO-URINARY  SURGERY 

it  would  escape  externally  if  it  came  from  the  anterior  urethra,  or  would  flow 
back  into  the  bladder  if  from  the  prostatic  urethra. 

When  all  the  urine  contains  blood,  but  that  last  passed  contains  the  greatest 
quantity,  the  last  few  drops  micturated  being  nearly  pure  bright  blood,  the  prob- 
abihty  of  the  vesical  or  prostatic  origin  of  the  bleeding  is  very  strong.  If  blood 
is  passed  only  at  the  end  of  micturition  (terminal  haematuria),  the  blood  must 
necessarily  coms  from  either  the  bladder  or  the  prostatic  urethra.  It  is  particu- 
larly in  prostatocystitis  that  terminal  hsematuria  is  observed.  The  bleeding  is 
not  profuse,  and  is  associated  with  other  symptoms  of  cystitis,  notably  frequency 
and  urgency. 

The  quantity  of  blood  in  the  urine  is  of  some  diagnostic  value.  If  the 
bleeding  is  apparently  causeless,  intermittent,  and  profuse,  it  is  usually  due  to 
renal  or  vesical  tumors,  though  tropical  parasites  in  the  urinary  tract,  notably 
the  distoma,  may  cause  severe  bleeding. 

Bleeding  may  be  caused  by  cantharides,  turpentine,  mercury,  or  the  ingestion 
of  certain  foods.  Renal  telangiectasis  has  been  reported  as  a  cause  for  blood  in 
the  urine,  and  this  symptom  regularly  follows  renal  thrombosis  and  infarcts. 

Essential  idiopathic  haematuria  implies  bleeding  from  a  healthy  kidney.  Con- 
vincing evidence  that  this  occurs  is  wanting,  though  it  is  true  that  vasomotor 
paresis  of  toxic  origin,  particularly  that  incident  to  a  wasting  infectious  disease, 
such  as  t3q3hoid  fever,  may  cause  blood  in  the  urine  without  demonstrable  adequate 
renal  lesion.  The  hemorrhage  in  such  a  case  may  be  so  alarming  as  to  threaten 
life. 

Blood  may  appear  in  the  urine  in  the  course  of  haemophilia,  or  because  of 
parasites  (Filaria  sanguinis  hominis),  closely  simulating .  the  surgical  forms  of 
haematuria.  When  it  is  due  to  infectious  fevers,  such  as  variola  or  scarlatina,  to 
dyscrasiae,  such  as  scurvy  or  purpura,  or  to  the  vasomotor  instability  of  hysteria, 
it  is  not  likely  to  be  confounded  with  haematuria  which  is  mainly  local  in  origin. 

When  haematuria  follows  sudden  muscular  action  or  apparently  insufficient 
violence,  this  is  probably  due  to  the  presence  of  a  hitherto  unsuspected  lesion. 
The  conditions  which  commonly  precede  the  bleeding  are  tumor,  tuberculosis, 
and  nephritis. 

In  general  terms,  when  urination  causes  bleeding,  stone,  tumor,  or  tuberculosis 
may  be  suspected.  Haematuria  due  to  new-growth,  whether  this  be  of  the 
bladder  or  of  the  kidney,  is  usually  profuse,  apparently  causeless,  intermittent, 
made  worse  by  exercise,  not  cured  by  rest.  The  freest  bleeding  may  come  from 
the  smallest  papilloma. 

A  tumor,  if  not  placed  near  the  vesical  neck,  may  occasion  no  symptoms 
other  than  hsematuria,  and  in  its  early  stages 'may  readily  escape  detection  by 
palpation. 

In  determining  the  source  of  bleeding,  evidence  afforded  by  analysis  of  asso- 
ciated symptoms  and  by  direct  examination  must  be  carefully  considered.'  If  the 
bladder  is  sufficiently  affected  to  cause  bleeding  from  its  mucous  membrane 
there  will  usually  be  frequency,  urgency,  and  pain  if  the  case  be  inflammatory 
or  traumatic:  or  a  bimanual  examination  will  show  some  alteration  in  the  vesical 
walls  or  in  the  prostate  if  there  be  infiltration  of  tumor. 

The  first  symptom  of  tumor  of  the  bladder  is  haematuria,  unless  the  growth 


EXAMINATION  OF  THE  PATIENT  9 

is  placed  near  the  vesical  orifice,  in  which  case  frequent  micturition  may  precede 
the  appearance  of  blood.    (Fenwick.) 

Tumors  of  the  bladder  are  often  complicated  by  cystitis. 

The  bleeding  from  chronic  Bright's  disease  is  moderate;  exceptionally  it  is 
intermittent  and  profuse.  In  acute  hemorrhagic  nephritis  the  loss  of  blood  may 
produce  a  serious  anaemia,  and  even  threaten  life.  Other  symptoms  of  the  dis- 
ease, and  particularly  the  results  of  urinary  examination,  suggest  the  cause  of 
hem.orrhage.  The  hemorrhage  of  syphilitic  glomerular  nephritis  can  be  diagnosed 
only  by  the  associated  symptoms  of  the  disease. 

Haematuria  of  renal  tuberculosis  is  characterized  by  pain,  often  amounting 
to  true  renal  colic,  pus  in  the  urine,  which  persists,  and  a  moderate  amount  of 
blood,  appearing  intermittently.  Renal  calculus  also  occasions  but  a  slight 
amount  of  bleeding  and  causes  pain  in  the  back  which  is  reflected  in  various 
directions,  the  bleeding,  the  attacks  of  colic,  and  the  pain  being  relieved  by  rest. 
The  same  amelioration  is  not  noted  in  either  tuberculosis  or  new-growths. 

Stone  in  the  bladder  causes  blood  in  moderate  quantity.  At  times  when 
the  stone  is  complicated  by  enlarged  prostate  blood  is  the  only  symptom. 
Bleeding  from  tuberculosis  of  the  bladder  is  also  slight,  occurring  particularly 
at  the  end  of  micturition.  The  effect  of  rest  upon  symptoms  of  stone  is  so 
marked  and  immediate  that  this  is  a  diagnostic  sign  of  distinct  value.  Haema- 
turia which  is  not  materially  influenced  by  either  exercise  or  rest  is  usually  due^ 
to  tuberculosis,  new-growth,  or  acute  inflammation. 

The  renal  and  vesical  hemorrhage  following  catheterization  of  an  overfull 
bladder  will  be  discussed  later  (see  p.  62).  Acute  cystitis  may  exceptionally 
cause  such  free  bleeding  that  the  term  hemorrhagic  is  applicable.  A  few  re- 
ported cases  seem  to  prove  that  varicose  veins  or  atheromatous  arteries  may 
by  rupturing  give  rise  to  serious,  even  fatal,  hemorrhage.  Enlarged  prostate  may 
also  cause  spontaneous  bleeding. 

The  final  determination  as  to  the  source  of  haematuria  must  depend  upon 
cystoscopic  examination.  Practically  it  is  only  in  cases  of  malignant  growth, 
or  possibly  in  those  of  tuberculosis,  that  associated  symptoms  fail  to  suggest 
the  origin  of  the  blood.  The  examination  may  be  made  either  in  the  interval 
•between  attacks  or  during  the  course  of  the  bleeding;  if  the  hemorrhage  is 
very  free  and  from  the  vesical  region,  nothing  can  be  seen,  since  ihe  fluid 
injected  into  the  bladder  at  once  becomes  opaque  from  admixture  of  blood. 
If  the  bleeding  is  of  renal  origin,  by  using  the  irrigating  or  evacuating  cysto- 
scope  the  blood  may  be  seen  escaping  from  the  ureter.  When  the  hemorrhage 
is  from  the  kidney  it  is  often  impossible  to  determine  the  affected  side  imless 
the  examination  is  made  at  the  time  of  the  bleeding. 

If  an  examination  made  after  bleeding  has  ceased  shows  that  the  bladder 
is  healthy,  this  of  course  points  to  the  renal  origin  of  bleeding.  If,  on  repeated 
trials,  fhe  urine  previously  having  been  nearly  or  quite  free  from  blood,  the 
introduction  of  the  cystoscope  at  once  occasions  such  free  hemorrhage  that 
examination  cannot  be  made,  this  is  itself  indicative  of  the  vesical  origin  of 
the  hemorrhage  and  almost  positively  points  to  new  growth. 

Treatment  of  Haematuria. — During  an  acute  attack  of  bleeding,  what- 
ever be  its  cause,  rest  in  bed,  liquid  diet,  preferably  milk  and  buttermilk,  and 


10  GENITO-URINARY  SURGERY 

diluent  drinks,  for  the  purpose  of  lessening  the  tendency  to  coagulation  in  the 
bladder,  are  advisable  on  general  principles.  The  lower  bowel  should  be 
kept  empty  by  means  of  enemata. 

Medication  by  the  mouth  is  of  little  value.  Guyon  speaks  well  of  turpen- 
tine. This  may  be  given  in  three-drop  doses  hourly  for  six  or  eight  hours, 
preferably  well  diluted  in  the  form  of  a  mucilaginous  emulsion.  Ergot  and 
ergotin  have  been  strongly  commended,  and  may  be  given  in  full  doses — a 
drachm  of  the  former  or  five  grains  of  the  latter  at  hourly  intervals.  Oil 
of  erigeron  also  seems  serviceable  at  times — thirty  drops  in  an  emulsion  re- 
peated in  one-half  hour,  followed  by  five-  to  ten-drop  doses  every  two  hours. 
Gallic  acid  is  credited  with  some  haemostatic  powers.  It  may  be  given  in 
ten-grain  doses  every  hour. 

When  the  bleeding  is  profuse  and  persistent,  injection  of  normal  human 
or  horse  blood-serum  is  indicated,  in  doses  of  ten  to  fifty  cubic  centimetres. 
If  there  be  tenesmus,  pain,  and  overdistention  of  the  bladder  from  clotting 
and  urethral  obstruction,  a  full  dose  of  morphine  should  be  administered  and 
the  bladder  emptied  by  the  catheter  and  suction  syringe.  This  may  be  fol- 
lowed by  irrigation  with  a  hot  astringent  antiseptic  solution,  such  as  silver 
nitrate  1  to  2000,  or  fluid  extract  of  hydrastis  (colorless)  an  ounce  to  one 
pint,  and  the  injection  of  a  half  ounce  of  adrenalin  chloride  1  to  5000,  or 
the  same  quantity  of  antipyrine  solution,  five  per  cent.  Antipyrine  possesses 
distinct  value  as  an  analgesic,  and  is  credited  with  being  a  powerful  haemostatic. 
Continuous  catheterization  is  indicated  till  the  bleeding  ceases.  If  the  use  of 
the  catheter  is  impracticable,  suprapubic  cystotomy  is  the  operation  of  choice, 
followed  by  the  removal  of  clots  and  the  insertion  of  a  large  drainage-tube. 

Most  minute  antiseptic  precautions  must  be  observed  in  all  these  manipu- 
lations, since  the  urinary  tract  in  case  of  bleeding  is  peculiarly  susceptible 
to  infection,  which  if  once  started  is  liable  to  resist  treatment  and  extend  rap- 
idly to  the  kidneys.     The  dangers  are  particularly  great  in  cases  of  neoplasm. 

The  bleeding  of  prostatics,  dependent  upon  the  intense  engorgement  which 
complicates  retention,  if  profuse  and  threatening  to  life,  is  best  treated  by 
evacuating  the  blood  by  means  of  a  catheter  and  syringe  and  keeping  the  bladder 
empty  by  the  retained  catheter.  If  the  clots  cannot  be  removed  in  this  way, 
perineal  or  suprapubic  cystotomy  is  indicated.  If  bleeding  persists,  pressure 
above  the  pubis,  applied  by  means  of  compresses,  must  be  tried. 

Hemorrhage  from  prostatitis  and  prostatocystitis  relieves  engorgement.  If 
moderate  it  is  often  benefited  by  balsams  combined  with  diluents  and  by  the 
rectal  use  of  opium.  The  same  treatment  is  applicable  to  tuberculous  cystitis. 
Renal  hemorrhage,  if  persistent  and  threatening  to  life,  should  be  treated  by 
exploratory  nephrotomy.  This  operation  is  often  curative  even  though  no 
cause  be  found  for  the  bleeding.  Further  detailed  treatment  of  haematuria  is 
given  in  the  sections  devoted  to  the  pathological  conditions  which  cause  it. 

Pyuria." — The  presence  of  pus  in  the  urine  is  indicative  of  the  existence 
of  an  area  of  inflammation  somewhere  in  the  urogenital  tract,  the  extent  of  the 
pyuria  giving  some  indication  of  the  severity  of  the  inflammation,  while  by 
following  it  to  its  source  we  are  surely  led  to  the  seat  of  trouble.     The  methods 


EXAMINATION  OF  THE  PATIENT  H 

whereby  this  is  accomplished  are  described  in  the  chapter  on  Examination  of  the 
Urine  (p.  14)/ 

Pyuria  can  usually  be  recognized  by  the  appearance  of  the  urine  as  it  is 
examined  by  transmitted  light;  occasionally,  as  in  cases  of  mild  pyelitis,  it  is 
necessary  to  examine  the  centrifugalized  urine  with  the  microscope  in  order  to 
detect  the  presence  of  pus  cells.  In  such  cases  the  pus  appears  in  the  form  of 
separate  cells. 

The  treatment  of  pyuria  is  necessarily  that  of  the  source,  since  the  condition 
is  merely  a  symptom  of  the  disease. 

Frequency  of  Urination. — Most  men  empty  the  bladder  upon  rising  in 
the  morning,  during  the  after-breakfast  defecation,  at  noon,  in  the  late  after- 
noon, and  before  going  to  bed,  passing  from  six  to  twelve  ounces  of  urine 
at  each  act  of  micturition.  In  warm  weather  urination  is  less  frequent,  the 
skin  relieving  the  kidneys. 

The  most  common  causes  of  frequency  of  urination  are  inflammation  of 
the  bladder  or  of  the  posterior  urethra,  or  some  mechanical  irritant  of  the 
bladder  mucosa,  as  a  calculus  or  tumor.  Occasionally  an  unsuspected  bac- 
teriuria  is  found  to  be  the  etiological  factor. 

The  bladder  is  said  to  be  irritable  when  the  desire  to  urinate  comes  too 
frequently.  This  irritability  may  be  entirely  of  psychic  origin — as,  for  in- 
stance, the  frequent  micturition  of  the'  student  subject  to  examination — or 
it  may  be  due  to  habit,  though,  unless  the  frequency  be  continued  through 
the  night,  this  does  not  lessen  the  absolute  capacity  of  the  bladder. 

The  irritability  may  also  be  caused  by  reflexes  from  the  rectum,  urethra, 
prostate,  seminal  vesicles,   testicles,  or  kidneys. 

It  may  be  due  to  increased  secretion  on  the  part  of  the  kidneys,  as  in 
diabetes.  In  this  case  the  bladder  is  not,  properly  speaking,  irritable,  since 
it  contains  urine  comfortably  up  to  its  full  normal  capacity,  but  has  to  be 
frequently  emptied  because  it  is  so  rapidly  filled. 

The  treatment  of  frequent  urination  is  founded  on  the  detection  and  re- 
moval of  the  cause,  and  is  given  in  the  sections  devoted  to  the  consideration 
•of  cystitis,  stone,  stricture,  cancer,  etc. 

There  is,  however,  one  form  of  frequent  urination  which  apparently  is 
purely  functional.  In  the  absence  of  urethral  lesions  or  pathological  condi- 
tions of  the  urine,  the  patient  is  unable  to  retain  his  water  more  than  one 
or  two  hours  at  a  time.  The  desire  to  urinate,  if  not  immediately  gratified, 
becomes  irresistible.  The  bladder  is  completely  emptied  at  each  act  of  micturi- 
tion.    There  is  usually  moderate  polyuria. 

This  condition  may  be  due  to  masturbation,  may  follow  sexual  excess  or 
prolonged  sexual  excitement,  or  may  develop  without  appreciable  cause.  It 
usually  affects  young  unmarried  men.  In  the  cases  we  have  observed  from 
four  to  six  ounces  could  be  retained  comfortably;  efforts  to  retain  more 
than  this  caused  great  distress.  In  one  case  between  seven  and  eight  ounces 
of  clear  urine  of  low  specific  gravity  (1.010)  were  passed  every  one  and  a 
■half  hours  during  the  day.  The  desire  to  urinate,  if  resisted,  caused  so  much 
suffering  that  the  patient  was  unable  to  attend  dinners  or  any  form  of  social 
entertainment  which  would  prevent  him  from  urinating  the  moment  he  felt 


12  GENITO-URINARY  SURGERY 

this  inclination.  His  sleep  was  uninterrupted,  and  if  his  bladder  was  emptied 
immediately  on  rising  he  experienced  no  distress,  usually  passing  from  twelve 
to  twenty  ounces. 

In  deciding  that  this  frequent  micturition  is  purely  functional  it  must  be 
remembered  that  a  similar  bladder  irritability  is  sometimes  symptomatic  of 
spinal  sclerosis,  particularly  that  form  associated  with  exaggerated  reflexes: 
hence  bladder  symptoms  should  always  lead  to  an  investigation  as  to  the 
condition  of  the  central  nervous  system.  Or  it  may  be  incident  to  arterio- 
sclerosis attacking  the  urinary  centres  of  the  cord  or  the  vessels  of  the  bladder. 

A  bladder  abnormally  small  from  congenital  formation,  from  long-continued 
nocturnal  and  diurnal  incontinence,  or  from  cicatricial  contraction,  may  cause 
a  form  of  frequent  urination  difficult  to  distinguish  from  that  which  is  purely 
functional.  The  frequenc}^,  if  due  to  contracted  bladder,  will  necessarily  be 
both  nocturnal  and  diurnal,  and  a  test  of  the  vesical  capacity  by  means  of 
bland  injections  will  demonstrate  the  nature  of  the  affection. 

The  treatment  of  this  purely  functional  frequency  is  at  first  mainly  dietetic 
and  hygienic.  Since  the  desire  is  often  not  felt  when  the  mind  and  body 
are  actively  engaged,  riding  the  bicycle  seems  particularly  serviceable,  both 
for  its  direct  effect  and  for  its  general  influence  on  the  health.  All  causes 
of  prostatic  congestion  orhypersesthesia  must  be  removed.  Sexual  excess,  pro- 
longed sexual  excitement,  and  constipation  are  to  be  avoided  most  carefully. 
Daily  cold  enemata  of  salt  water  (a  drachm  to  the  pint)  are  serviceable 
as  means  of  emptying  the  lower  bowel.  Hemorrhoids  should  be  cured,  a 
redundant  foreskin  removed,  varicocele  relieved  by  a  suspensory  or  subjected 
to  radical  operation,  an  abnormally  small  meatus  enlarged;  in  fact,  every 
possible  cause  of  reflex  excitability  should  receive  attention. 

The  local  treatment  has  for  its  object  the  relief  of  hypersesthesia  and 
congestion  of  the  prostatic  urethra.  This  is  accomplished  by  full-sized  cold 
steel  sounds,  the  direct  application  of  electricity,  instillations,  rectal  irriga- 
tions, applications  of  heat  or  cold,  and  prostatic  massage.  The  details  of 
these  methods  are  given  in  the  section  devoted  to  the  treatment  of  impotence. 

The  medicinal  treatment  should  be  confined  in  the  main  to  constructives, 
tonics,  and  stimulants.  Potassium  bromide  theoretically  should  be  service- 
able, since  it  lessens  reflex  excitability.  We  have  generally  found  it  useless. 
Hyoscine  and  hyoscyamine  in  doses  of  from  one  two-hundredth  to  one  one- 
hundredth  of  a  grain  thrice  daily,  and  belladonna  suppositories,  each  con- 
C9ntaining  one-third  of  a  grain  of  the  extract,  have  given  us  better  results 
than  any  of  the  many  drugs  commended. 

It  should  be  clearly  recognized  that  this  affection  when  it  has  been  of 
long  standing  is  extremely  obstinate  to  treatment,  and  that  cure,  if  it  can 
be  accomplished  at  all,  is  at  the  expense  of  months  of  patient,  not  too  officious, 
treatment.  Marriage,  with  its  consequent  regularity  of  sexual  relations,  favor- 
ably affects,  or  even  entirely  cures,  this  form  of  frequent  urination. 

Frequent  urination  due  to  a  bladder  small  from  conformation  or  because 
of  prolonged  non-retention  (habit  frequency)  is  best  treated  by  daily  pro- 
gressive dilatation,  accomplished  by  means  of  a  fountain  syringe,  elevated 
three   feet    above   the   bladder,    and   a   short   urethral    nozzle   or   soft-rubber 


EXAMINATION  OF  THE  PATIENT  13 

catheter.  The  urine  is  passed,  and  the  bladder  is  then  distended  with  warm 
sterile  four  per  cent,  boric  acid  solution  till  further  injection  becomes  un- 
bearable to  the  patient.  The  injected  liquid  is  allowed  to  flow  out  slowly, 
and  the  distention  is  repeated.  This  treatment  is  repeated  daily  or  every 
second  day  till  from  eight  to  twelve  ounces  of  urine  can  be  retained  com- 
fortably. 

Hydraulic  distention  is  absolutely  inadmissible  when  the  bladder  cavity 
is  lessened  because  of  tuberculous  involvement. 

Alterations  in  the  Stream. — Urine  driven  by  a  healthy  bladder  through 
a  normal  urethra  should,  unaided  by  abdominal  strain,  flow  from  the  meatus 
in  a  steady  twisting  stream,  which,  if  it  be  directed  horizontally  forwafd, 
should  fall  from  three  to  five  -feet  away  from  the  vertical  line  of  the  body. 
When  the  muscular  walls  of  the  bladder  are  weakened,  or  when  the  urethra 
is  obstructed,  this  stream  is  necessarily  altered  in  volume,  force,  and  direc- 
tion. Irregularity  in  muscular  effort  or  sudden  blockage  of  the  urethra  breaks 
the  continuity  of  the  stream. 

A  small,  forked,  badly  aimed,  but  forcible  stream  points  to  narrowing  at 
or  near  the  meatus. 

A  forcible,  large  stream,  suddenly  and  for  a  time  permanently  interrupted, 
points  to  stone  or  other  foreign  body  in  the  bladder;  a  stream  becoming  slowly 
smaller  and  less  forcible,  and  ultimately  dropping  directly  down  from  the 
end  of  the  penis,  points  to  enlargement  of  the  prostate  or  to  urethral  stric- 
ture placed  far  back ;  it  also  may  be  due  to  acute  congestion,  chronic  prostatitis, 
atony  of  the  bladder,  tumor  formation,  or  extra-urethral  pressure. 

A  stream  which  has  become  gradually  small  and  lacking  in  force,  and 
which  is  suddenly  arrested,  may  be  due  to  congested  stricture,  congested  en- 
larged prostate,  or  impacted  stone. 

A  fairly  forcible  stream  which  is  intermittently  and  irregularly  stopped  for 
a  moment  at  a  time — the  so-called  "stuttering  urination" — is  due  to  vesical 
spasm,  and  is  either  a  neurosis  or  a  reflex. 


CHAPTER  II       . 

EXAMINATION  OF  THE  URINE,  OF  EXUDATES  AND 
SECRETIONS,  AND  OF   KIDNEY   FUNCTION 

For  the  purposes  of  the  genito-urinary  surgeon  the  urine  must  be  examined 
from  the  standpoint  of  the  "medical"  condition  of  the  kidneys,  and  from  the 
standpoint  of  the  recognition  of  surgical  lesions  in  the  urinary  tract  or  in  the 
communicating  genital  organs  (Plate  I  and  Fig.  1).  For  the  former  the  exami- 
nation is  similar  to  that  conducted  in  ordinary  medical  cases;  for  a  description 
of  the  methods  employed  the  reader  is  referred  to  text-books  of  clinical  labora- 
tory technique.  One  point,  however,  it  is  desired  to  emphasize,  and  that  is 
the  necessity  of  ascertaining  the  total  quantity  of  urine  voided  in  the  24  hours, 
and  of  taking  this  into  consideration  in  making  deductions  from  the  findings  of 
the  laboratory  examination.  The  average  amount  of  urine  secreted  in  a  day 
is  from  two  to  three  pints;  an  elimination  of  less  than  one  pint  is  in  itself 
cause  for  alarm. 

The  second  portion  of  the  examination  includes  the  determination  of  the 
organ  which  is  the  seat  of  the  pathological  process,  and  the  nature  of  the  disease. 
The  first  requisite  in  the  examination,  therefore,  is  to  ascertain  from  what  part 
of  the  tract  the  elements  observed  are  derived.  This  is  done  in  part  by  mechani- 
cal means,  by  use  of  the  ''glass  tests,"  supplemented  when  needful  by  the  use 
of  urethral  and  ureteral  catheters,  and  in  part  by  observing  the  character  of  the 
epithelial  cells  in  the  urinary  sediment.  The  former  method  is  the  more  accurate 
and  valuable. 

THE  GLASS  TESTS 

The  interpretation  of  the  distribution  of  pathological  elements  in  the 
several  receptacles  into  which  urine  has  been  voided  depends  so  intimately 
on  a  knowledge  of  the  action  of  the  muscles  of  the  posterior  urethra  that 
a  brief  description  of  the  points  on  which  the  test  depends  is  here  given. 
Urine  is  retained  in  the  bladder  by  the  action  of  muscles  situated  at  the 
vesical  orifice  and  at  the  lower  end,  or  apex,  of  the  prostate  gland.  The  first 
of  these,  the  internal  vesical  sphincter,  is  composed  of  involuntary  fibres;  the 
second  really  consists  of  two  muscles,  the  external  vesical  sphincter  (unstriated 
muscle)  and  the  compressor  urethrae  or  "cut-off  muscle"  (striated  muscle), 
continuous  with  one  another  and  apparently  closely  related  in  their  function, 
and  hereafter  collectively  called  the  external  sphincter.  The  external  sphincter 
is  much  more  powerful  than  the  internal.  This  has  two  results;  when  pus 
is  secreted  in  the  prostatic  urethra  it  tends  to  flow  backwards  into  the  blad- 
der, and  there  mingle  with  the  urine  rather  than  to  appear  at  the  meatus; 
moreover,  if  there  is  momentary  relaxation  of  the  internal  sphincter  and 
urine  enters  the  prostatic  urethra,  its  further  progress  is  prevented  by  the 
external  sphincter,  which,  stimulated  by  the  presence  of  urine  in  the  prostatic 
urethra,  contracts  strongly  to  repel  its  further  advance,  while  with  it  con- 

.  14 


EXAMINATION  OF  THE  URINE 


15 


B 


K 


J 


L 


^t-     '^^ 


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m^^ 


M 


M 


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e> 


Fig.  1. — Organic  urinary  constituents.  A. — Hyaline  casts.  B. — Blood-casts.  C. — 
Epithelial  cells  (various  forms).  D. — Erythrocytes.  £. — Fatty  casts.  F. — Waxy  casts. 
G. — Light  and  dark  granular  casts.  H. — Pus  cells.  /. — Compound  granule  cells  (prostatic). 
J. — Spermatozoa.       K. — Cylindroids.      L. — Saccharomyces    (yeast).       I/. — Epithelial    casts. 


16  GENITO-URINAR!.r  SURGERY 

tracts  the  whole  musculature  of  the  perineum,  and  probably  also  the  prostate, 
so  that  the  urine  is  forced  back  into  the  bladder,  carrying  with  it  whatever 
debris  may  lie  in  the  part  of  the  urethra  invaded.  On  account  of  the  differ- 
ence in  the  behavior  of  pus  formed  in  front  of  and  behind  the  external  sphincter, 
as  well  as  for  certain  differences  in  the  physiology  of  the  two  portions  of  the 
canal,  that  portion  of  the  urethra  lying  in  front  of  this  sphincter  is  called 
the  anterior  urethra,  as  contrasted  with  the  posterior  urethra,  that  portion 
of  the  canal  lying  between  the  extenal  sphincter  and  the  bladder. 

For  the  proper  interpretation  of  any  of  the  glass  tests  it  is  essential  that 
the  patient  have  held  his  urine  for  at  least  four  hours  prior  to  the  examina- 
tion. Tall  cylinders  holding  about  six  ounces  are  most  suitable  for  the  recep- 
tion of  the  urine. 

Two-glass  Tests. — The  first  glass  contains  the  washings  of  the  whole  urethra; 
the  second  glass  contains  secretions  from  organs  proximal  to  the  external 
sphincter  (posterior  urethra,  prostate,  bladder,  etc.).  Interpretation:  First 
glass  cloudy  and  second  clear  signifies  an  anterior  urethritis;  fallacy,  with 
very  little  discharge  from  the  posterior  urethra,  no  pus  may  make  its  way 
back  into  the  bladder,  and  a  posterior  urethritis  may  thus  escape  detection. 
Both  glasses  cloudy  signifies  anteroposterior  urethritis;  fallacies,  when  very 
little  urine  is  voided  the  anterior  urethra  may  be  imperfectly  cleansed,  and 
a  simple  anterior  urethritis  be  mistaken  for  one  of  the  whole  canal,  or  the 
disease  may  be  situated  farther  up  the  tract. 

Three-glass  Test. — The  urine  is  voided  in  a  continuous  stream  into  three 
glasses,  the  last  portion  being  passed  with  as  much  straining  as  possible.  The 
first  two  glasses  are  the  same  as  in  the  preceding  test;  the  last  contains, 
in  addition  to  the  contents  of  the  second  glass,  material  squeezed  from  the 
prostatic  ducts  by  the  contractions  of  the  rrjusculature  of  that' body. 

In  order  to  avoid  some  of  the  fallacies  incident  to  the  tests  just  mentioned, 
several  tests  have  been  devised  wherein  irrigation  of  the  anterior  urethra  is 
used  to  free  this  portion  of  the  canal  of  pus  and  mucus.  The  irrigations  may 
be  performed  by  means  of  an  irrigator  and  blunt  urethral  nozzle,  with  a  hand 
syringe,  or  with  a  small,  soft-rubber  catheter  or  glass  tube  attached  to  a 
reservoir.    Kollman's  five-glass  test  is  typical  of  this  class.     In  it — 

Glass  1  contains  the  washings  of  the  anterior  urethra. 

Glass  2  is  a  control   (additional  washings). 

Glasses  3,  4,  and  5  contain  urine  voided  in  a  continuous  stream;  glass  3 
therefore  contains  secretions  from  the  posterior  urethra,  glass  '4  is  a  control 
of  glasses  3  and  5,  and  glass  5  is  the  same  as  glass  3  of  the  three-glass  test. 

The  examination  of  the  secretions  of  the  prostate  and  seminal  vesicles  is 
described  in  the  sections  devoted  to  those  organs,  (pp.  392  and  377). 

The  pathological  secretions  of  a  diseased  bladder  cannot  be  mechanically 
separated  from  those  of  the  posterior  urethra. 

Urine  from  the  kidneys  and  ureters  can  be  collected  by  means  of  ureteral 
catheters  introduced  through  a  cystoscope. 

"Staining"  Test. — This  test  is  useful  when  there  is  some  doubt,  after  the 
performance  of  the  other  glass  tests,  as  to  the  condition  of  the  posterior  urethra. 
The  anterior  urethra  is  irrigated  as  in  the  preceding  test.    With  a  small  urethral 


EXAMINATION  OF  THE  URINE  17 

syringe  about  two  drachms  of  a  1  per  cent,  solution  of  methylene  blue  or 
some  similar  stain  is  then  injected  into  the  anterior  urethra  and  retained  for 
one  minute,  after  which  it  is  allowed  to  escape  and  the  anterior  urethra  irri- 
gated for  a  second  time,  to  free  it  from  the  excess  of  stain.  The  urine  is  then 
voided,  sedimented,  and  the  deposit  examined  with  the  microscope.  The  pres- 
ence of  unstained  pus-cells  is  indicative  of  disease  above  the  compressor  muscle, 
usually  of  a  posterior  urethritis. 

Cytologic   Localization 

Localization  of  the  site  of  a  lesion  may  sometimes  be  accomplished  by 
microscopical  examination  of  the  urine.  Such  localization  depends  upon  the 
fact  that  in  the  presence  of  inflammation  there  is  always  desquamation  of  a 
certain  number  of  epithelial  cells.  It  is  only  by  a  study  of  these  that  localiza- 
tion can  be  accomplished.  The  most  important  point  to  be  considered  in 
deciding  from  what  region  a  given  cell  has  come  is  size.  There  is  some  varia- 
tion in  the  size  of  cells  coming  from  a  given  region  in  one  individual,  but  by 
selecting  an  average  cell,  and  taking  into  consideration  the  character  of  the 
other  cells  in  the  specimen,  it  is  said  to  be  nearly  always  possible  to  cor- 
rectly name  the  organ  from  which  the  element  came  (Heitzmann). 

The  largest  epithelial  cells  are  those  from  the  vagina.  Those  coming 
from  the  most  superficial  layer  of  the  vesical  mucosa,  either  sex,  are  the  next 
smaller;  then  come  those  from  the  cervix  uteri,  the  urethra,  the  pelvis  of  the 
kidney,  the  ureter,  the  prostate,  and  the  uriniferous  tubules  of  the  kidney. 
The  smallest,  those  from  the  kidney  tubules,  are  about  one-third  larger  than 
the  pus-corpuscles  of  the  patient  examined,  so  these  cells  are  to  be  taken 
as  the  standard  of  comparison.  Cells  from  the  convoluted  tubules  are  cuboidal 
(generally  spherical  on  account  of  absorption  of  water  from  the  urine) ;  cells 
from  the  straight  tubules  are  columnar.  The  cells  from  the  ureters  are  larger, 
about  three  times  the  size  of  a  pus-cell.  They  are  spherical  and  morphologically 
identical  with  the  cells  from  the  interior  of  the  prostate.  The  cells  from  the 
pelvis  of  the  kidney  are  a  little  larger,  usually  caudate,  near-shaped,  or  lenticu- 
lar. From  the  urethra  the  cells  of  the  upper  layer  are  flat  and  polygonal, 
from  the  deeper  layers  globular  or  columnar.  The  shape  of  the  large  cells 
from  the  bladder  also  varies  according  to  their  situation,  in  the  same  manner 
as  do  those  from  the  urethra. 

QUALITATIVE  EXAMINx^TION 

The  freshly  voided  urine  should  be  examined  by  transmitted  light  as  to 
its  color  and  clarity,  the  former  being  an  indication  of  its  concentration  and 
of  the  presence  or  absence  of  blood,  the  latter  of  its  relative  freedom  from  pus, 
mucus,  bacteria,  semen,  shreds  of  tissue,  and  inorganic  crystalline  or  amorphous 
precipitates.  The  odor  of  the  urine,  whether  normal,  ammoniacal,  or  putrid,  is 
also  to  be  noted. 

Some  of  the  solid  particles  in  the  urine  can  be  recognized  by  the  naked 

eye,  while  others  require  chemical  tests  or  the  use  of  the  microscope.     Thus 

shreds  which  are  short,  thick,  and  sink  rapidly  to  the  bottom  of  the  vessel 

are  composed  mainly  of  pus,  while  those  which  are  long,  thin,  and  float  in 

2 


18  GENITO-URINARY  SURGERY 

the  upper  part  of  the  urine  have  a  considerable  amount  of  mucus  in  their  com- 
position. Of  the  substances  which  cause  diffuse  clouding  of  the  urine  (pus, 
phosphates,  urates,  bacteria,  and  semen),  phosphates,  with  carbonates,  occur 
in  neutral  or  alkaline  urine  and  disappear  on  the  addition  of  an  acid;  pus 
is  best  demonstrated  by  the  use  of  the  microscope;  in  the  vast  majority  of  cases 
it  is  the  cause  of  clouding  in  acid  urine;  the  clouding  due  to  urates  disappears 
on  heating  the  urine;  the  microscope  is  necessary  to  recognize  bacteria  or 
semen  as  the  cause  of  clouding;  amorphous  phosphates  and  urates  are  indis- 
tinguishable by  means  of  the  microscope. 

Hccmaturia  and  Harmoglobinuria.— The  presence  of  red  blood-cells  or  their 
coloring  matter,  according  to  the  amount  present,  affects  the  color  of  the  urine 
not  at  all,  or  gives  it  a  pink  tinge  or  deep-red  color.  The  laboratory  differ- 
entiation of  the  two  conditions  depends  on  the  finding  of  red  blood-cells  in 
the  case  of  haematuria;  if  the  two  conditions  coexist,  the  amount  of  haemoglobin 
present  is  out  of  proportion  to  the  number  of  blood-cells. 

The  presence  of  haemoglobin  or  blood  can  be  recognized  by  means  of  the 
spectroscope  or  by  chemical  tests.  Of  the  latter,  the  most  easily  performed 
is  Heller's  test:  A  small  portion  of  the  urine,  or,  better,  of  the  urinary  sedi- 
ment, is  rendered  strongly  alkaline  with  sodium  hydrate  and  boiled.  In  the 
presence  of  haemoglobin  the  phosphatic  precipitate  which  forms  on  standing 
has  a  bright-red  color,  due  to  the  formation  of  haemochromogen.  If  the  amount 
of  blood  is  very  small,  or  there  is  doubt  as  to  its  presence  on  account  of  the 
interference  of  bile-coloring  matter,  the  precipitate  should  be  caught  on  filter- 
piper  and  dissolved  with  acetic  acid,  the  resulting  solution  being  red  in  the 
presence  of  blood-pigment,  the  color  gradually  fading  on  exposure  to  the  air. 
The  test  is  said  to  detect  the  presence  of  oxyhaemoglobin  when  present  in  the 
proportion  of  1  to  4000. 

Microscopical  Examination. — The  urine  should  be  sedimented  for  this  ex- 
amination, preferably  by  means  of  a  centrifuge;  if  a  power  centrifuge,  either 
water  or  electric,  be  employed,  and  a  definite  time  (e.g.,  three  minutes)  be 
allowed  for  the  process,  the  results  will  be  most  uniform. 

For  many  examinations  the  sediment  may  be  simply  taken  up  with  a 
pipette,  placed  on  a  slide,  and  examined  in  the  fresh  condition.  This  exami- 
nation suffices  to  differentiate  pus-,  blood-,  and  epithelial  cells.  For  more 
minute  examinations,  especially  for  the  demonstration  of  bacteria,  it  is  neces- 
sary that  the  specimens  be  dried,  fixed,  and  stained.  The  sediment  is  most 
satisfactorily  fixed  to  the  slide  by  first  smearing  the  glass  with  a  dilute  solution 
of  egg-albumen,  adding  the  sediment  for  examination  when  the  albumen  is 
nearly  dry.  The  specimen  is  fixed,  after  it  has  become  entirely  dry,  by  passing 
through  the  flame.  In  most  cases  simply  drying  the  sediment  on  the  slide 
and  passing  it  through  the  flame  suffices  to  fix  it. 

Smears  of  purulent  secretions  should  be  prepared  in  the  same  way  as 
blood  smears,  a  small  drop  being  placed  in  the  middle  of  a  clean  cover-glass, 
a  second  cover-glass  applied  so  that  the  secretion  is  spread  in  a  thin  film 
between  the  two,  and  the  films  slid  apart.  They  are  then  allowed  to  dry  in 
the  air,  and  passed  once  or  twice  through  the  flame  of  a  Bunsen  burner  in 
order  to  fix  them. 


PLATE  II. 


C^j 


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J^i 


r* 


Ik 


*^  *- 


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A 

Pus  of  acute  gonorrhoea  (eosin-azur). 


^ 


^ 


^.^ 


% 


Pus  of  acute  gonorrhoea  with  mixed  infection 
(Gram's    method,  safranin  counterstain) . 

%    ^^^  *     h  %  ^' 

^     Is  • 


*  « 


'•c^. 


^ 
^ 


B 

Pus  of  "pyogenic"  urethritis  (eosin-azur). 


Pus   of  acute  "pyogenic"    urethritis  (Gram's 
method,  safranin  counterstain). 


PLATE  III. 


^0 


^5 


f 


>•  .:t.v, 


£" 


.'  ^ 


■■n 


*y  -^V' 


•A    ■•  V  ;,    '  ' 


Pus  of  subacute  gonorrhoea  with  mixed 
infection  (Gram's  method,  Bismarck  brown 
counterstain). 


B 

Shred   of  gleet    (Loeffler's   methylene   blue). 


EXAMINATION  OF  THE  URINE  19 

Stains. — Three  methods  of  staining  are  extensively  used  in  genito-urinary 
investigations:  simple  monochromatic  or  bichromatic  staining,  staining  by  Gram's 
method,  and  staining  acid-fast  bacteria  by  the  method  of  Gabbett. 

For  the  first  of  these  any  of  the  following  are  recommended  for  routine 
use:  Ehrlich's  anilin  methylene  blue,  Unna's  polychrome  methylene  blue,  Giem- 
sa's  eosin-azur  (Plate  II,  A  and  B)  (used  also  for  the  Treponema  pallidum), 
and  carbol-thionin,  made  up  as  follows: 

French  thionin 0.5  Gm. 

Alcohol,  95  per  cent. 10.  c.c. 

Phenol,  5  per  cent 90.  c.c. 

Gram's  method  of  staining,  important  especially  in  the  recognition  of  the 
gonococcus  (Plate  II,  C  and  D,  and  Plate  III,  A),  is  performed  as  follows: 

(a)  Stain  for  three  minutes,  film  side  down,  in  anilin  water,  gentian  violet 
(prepared  by  shaking  1  c.c.  of  anilin  oil  with  12  to  15  c.c.  of  distilled  water 
in  a  test-tube,  filtering  through  wet  paper  into  a  watch  crystal,  and  adding 
saturated  aqueous  solution  of  gentian  violet  till  the  solution  adhering  to  the 
sides  of  the  glass  after  tipping  is  distinctly  colored — 4  to  6  drops;  the  stain 
must  be  prepared  fresh  daily). 

(b)  Shake  off  excess  of  stain,  and  submerge  in  or  apply  Gram's  iodine 
solution  for  one  minute  (iodine,  1  part;  potassium  iodide,  2  parts;  water,  300 
parts;  this  solution  must  be  discarded  when  it  begins  to  lose  its  deep  "iodine" 
color). 

(c)  Decolorize  in  alcohol,   95   per  cent.,   till  color  ceases  to   come  away. 

(d)  Wash  in  water. 

(e)  Counterstain  with  safranin,  20  drops  of  saturated  watery  solution  to 
J/2  ounce  of  water,  or  1  drop  of  saturated  alcoholic  solution  of  fuchsin  in  a 
watch-crystal  (}i  ounce)  of  water,  for  ^2  to  1  minute. 

Acid- fast  bacteria  are  stained  by  the  following  method: 

(a)  Apply  carbol-fuchsin  stain  (100  c.c.  of  5  per  cent,  phenol  added  to 
fuchsin,  1  Gm.  dissolved  in  10  c.c.  alcohol)  for  five  minutes. 

{b)  Decolorize  and  counterstain  with  Gabbett's  solution  (1  to  2  per 
cent,  methylene  blue  in  25  per  cent,  sulphuric  acid)  till  the  red  color  has 
disappeared,  or  decolorize  with  1  per  cent,  hydrochloric  acid  in  alcohol  and 
counterstain. 

The  acid-fast  bacteria  likely  to  be  seen  are  the  tubercle  and  smegma  bacilli. 
They  are  morphologically  indistinguishable;  however,  if  the  meatus  be  thor- 
oughly cleansed,  and  a  catheter  be  used  for  the  collection  of  the  urine,  there 
is  practically  no  danger  of  contamination  by  the  smegma  bacillus,  so  that 
under  such  circumstances  the  finding  of  a  red  rod  in  a  smear  is  sufficient  basis 
for  the  formation  of  a  diagnosis  of  tuberculosis. 

The  search  for  the  tubercle  bacillus  in  urine  is  often  a  very  tedious  pro- 
cedure. The  sediments  from  twenty-four  specimens  of  urine  must  be  em- 
ployed, these  being  further  concentrated  by  centrifugation.  The  work  is 
rendered  easier  by  mixing  the  sediment  with  about  one-fourth  its  volume  of 
antiformin  and  allowing  it  to  stand  for  twenty-four  hours.  All  organic  matter 
save  the  tubercle  bacilli  is  thus  oxidized. 


20  GENITO-URINARY  SURGERY 

Animal  Inoculations. — The  surest  and  most  accurate  method  of  demon- 
strating the  presence  of  tubercle  bacilli  is  by  the  inoculation  of  guinea-pigs. 
This  may  be  done  intraperitoneally  or  subcutaneously. 

In  intraperitoneal  inoculation  3  to  5  c.c.  of  the  centrifugalized  urinary 
sediment  is  heated  to  60^  C.  for  ten  minutes  to  kill  pyogenic  bacteria,  cooled, 
and  injected.  Autopsy  is  performed  in  six  weeks.  This  is  probably  the  surer 
of  the  two  methods. 

In  subcutaneous  inoculation  the  injection  is  made  near  the  inguinal  lymph- 
nodes,  which  have  been  previously  bruised  with  the  fingers.  After  ten  days 
the  nodes  are  excised,  crushed  between  glass  slides,  and  stained  by  Gabbett's 
method,  or  examined  histologically  for  tuberculosis. 

DETERMINATION  OF  KIDNEY  FUNCTION 

Tests  for  the  determination  of  the  relative  integrity  of  the  kidneys  are 
useful  for  three  purposes:  to  ascertain  whether  the  "combined"  or  "total  func- 
tion" of  the  two  kidneys  is  sufficient  to  warrant  the  administration  of  an  anaes- 
thetic and  the  performance  of  an  operation,  especially  an  operation  on  the 
genito-urinary  organs;  secondly,  to  determine  whether  one  of  the  kidneys 
is  the  seat  of  disease  by  ascertaining  the  comparative  function  of  the  two 
sides;  and,  thirdly,  to  determine  whether,  in  the  event  of  the  removal  of  one 
kidney,  the  other  is  capable  of  performing  the  total  renal  function  for  the 
organism. 

The  requirements  of  the  test  are  that  it  should  be  reasonably  accurate, 
should  be  without  deleterious  effect  upon  the  patient,  and  that  its  applica- 
tion should  not  be  complicated.  A  large  number  of  tests  have  been  proposed. 
Of  these,  those  which  appear  to  be  the  most  valuable  are  the  indigocarmin  test, 
the  phenolsulphonephthalein  test,  the  urea  nitrogen  and  the  total  nonprotein 
nitrogen  of  the  blood. 

The  interpretation  of  the  results  of  the  tests  usually  presents  no  difficulties. 
In  doubtful  cases  it  is  advisable  to  make  use  of  more  than  one  test  in  order 
to  get  as  much  information  as  possible.  Of  the  three  tests  mentioned,  indigo- 
carmin and  phenolsulphonephthalein  may  be  considered  tests  of  renal  elimination, 
while  the  blood  urea  nitrogen  and  total  nonprotein  are  regarded  as  tests  of 
retention. 

When  there  is  doubt  as  to  the  operability  of  a  case  the  tests  should  al- 
ways be  repeated  after  the  lapse  of  several  days  or  weeks,  during  which  such 
palHative  measures  as  drainage  of  the  bladder  have  been  instituted.  If  subse- 
quent tests  show  an  improving  kidney  function,  operation  is  sometimes  per- 
missible in  the  presence  of  findings  which  with  a  decreasing  or  stationary  func- 
tion would  be  an  absolute  contra-indication. 

Indigocarmin. — The  indigocarmin  test  is  the  most  easily  performed,  and 
seems  to  be  the  most  reliable.  Its  chief  disadvantage,  the  traumatism  to  the 
tissues  occasioned  by  the  injection  of  20  c.c.  of  fluid  and  the  resultant  soreness, 
can  be  overcome  by  intravenous  administration. 

The  test  is  performed  by  injecting  a  solution  of  the  drug  (20  c.c.  of  a  0.4 
per  cent,  solution  in  physiological  saline)  either  intramuscularly  or  intra venously^ 
and  noting  the  time  elapsing  before  its  elimination,  and  when  in  doubt  as  to  the 


EXAAIINATION  OF  THE  URINE  21 

proper  interpretation,  by  estimating  the  percentage  eliminated  hour  by  hour 
for  three  hours.  When  the  intravenous  method  is  used  and  the  time  of  appear- 
ance only  is  to  be  determined,  4  c.c.  of  the  0.4  per  cent,  solution  is  a  sufficient 
dose.  It  may  be  conveniently  carried  in  small  ampoules  which  have  been 
sterilized  in  a  water-bath  after  filling. 

When  the  combined  function  only  is  desired  the  observations  may  be  made 
with  the  aid  of  a  urethral  catheter,  or  by  having  the  patient  void  at  intervals 
when  there  is  no  residual  urine.  When  a  determination  of  unilateral  kidney 
function  is  necessary,  simple  observation  of  the  appearance  of  the  blue  at 
the  ureteral  orifices  lay  means  of  a  cystoscope  (Plate  V,  d)  is  all  that  is 
is  required;  ureteral  catheterization  is  neither  essential  nor  desirable,  on  ac- 
count of  the  possibility  of  reflex  inhibition  of  the  kidneys  from  the  presence 
of  the  catheter.  For  this  reason  the  test  is  applicable  to  cases  in  which  the 
ureteral  openings  are  visible  though  they  cannot  be  catheterized,  and  to  cases 
in  which  it  is  not  possible  to  identify  the  orifices  on  account  of  the  nature 
of  the  surrounding  bladder  surface  without  the  aid  of  the  elimination  of  col- 
ored urine. 

The  dye  is  sterilized  by  boiling  in  a  small  flask  immediately  before  injec- 
tion; when  used  intravenously  it  should  also  be  filtered.  In  has  no  toxic 
properties. 

From  "functionally  sufficient"  kidneys  the  dye  is  eliminated  as  "dark  blue" 
in  from  three  to  twenty  minutes;  occasionally  elimination  occurs  as  "light 
blue,"  in  which  case  fifteen  minutes  is  to  be  considered  as  the  limit.  The 
above  figures  have  reference  to  the  time  of  elimination  when  the  injection  has 
been  made  intramuscularly  (the  upper,  outer  third  of  the  gluteal  region  is 
usually  selected).  When  the  intravenous  route  is  employed  a  delay  of  more 
than  seven  or,  at  the  most,  ten  minutes  should  be  considered  an  indication  of 
insufficiency. 

In  cases  in  which  there  is  some  doubt  as  to  kidney  sufficiency  a  quantitative 
determination  should  be  made  of  the  percentage  excreted  each  hour  during 
the  first  three  hours  after  injection  by  means  of  a  colorimeter.  Normal  kid- 
neys excrete  from  25  per  cent,  to  40  per  cent,  of  the  amount  injected  during 
this  three-hour  period;  a  trifle  more  is  excreted  when  the  intravenous  route  is 
used  than  when  the  drug  is  given  by  the  intramuscular  method,  and  a  larger 
percentage  is  found  in  the  first  hour's  portion.  Normally  the  percentage  elim- 
inated in  the  first  hour  greatly  exceeds  that  found  in  the  third  hour's  specimen; 
namely,  in  the  ratio  of  5:1  (so-called  index  oj  elimination)]  an  approximation 
of  the  two  amounts,  especially  surpassing  of  the  first  hour's  by  the  third  hour's, 
should  be  considered  as  a  contra-indication  to  operations  of  the  severity  of  a  pros- 
tatectomy. 

Phenolsulphonephthalein  was  introduced  to  the  medical  profession  as  a 
means  of  determining  kidney  function  by  Geraghty  and  Rowntree  in  1910. 
It  is  quite  reliable  as  an  indicator  of  kidney  condition,  and  the  method  of 
its  application  is  not  complicated.  It  is  excreted  almost  entirely  by  the  kid- 
neys, in  a  comparatively  short  space  of  time  in  normal  cases.  It  has  a  beau- 
tiful red  color  in  alkaline  solution;  in  acid  solution  it  has  a  rather  deep 
yellow  color. 


22  GENITO-URIXARY  SURGERY 

One-half  hour  before  the  injection  of  the  dye  the  patient  should  drink  from 
300  to  500  c.c.  of  water,  to  insure  a  free  flow  of  urine.  The  test  is  performed 
by  injecting,  either  intramuscularly  or  intravenously,  6  mg.  of  the  dye  in  1  c.c. 
of  solution.  The  solution  is  but  very  slightly  irritating.  In  normal  cases 
elimination  begins  in  from  five  to  eleven  minutes  after  intramuscular  and  in 
three  to  five  minutes  after  intravenous  administration.  As  it  has  been  found 
that  the  onset  of  elimination,  early  or  late,  has  a  definite  relationship  to  the 
rate  of  elimination,  rapid  or  slow,  it  is  the  present  custom  to  omit  the  deter- 
mination of  the  former  point  and  simply  to  collect  the  urine  at  the  end  of 
one  hour  and  ten  minutes  and  of  two  hours  and  ten  minutes  (ten  minutes 
being  allowed  for  the  appearance  of  the  dye),  and  to  then  determine  the  amount 
excreted  in  these  periods  by  means  of  a  colorimeter.  The  authors  of  the  test 
state  that  from  50  per  cent,  to  60  per  cent,  of  the  dye  injected  intramuscu- 
larly is  excreted  by  normal  kidneys  during  the  first  hour,  and  from  60  per 
cent,  to  80  per  cent,  during  the  first  two  hours;  these  figures  are  a  little  higher 
than  those  reported  by  the  majority  of  investigators.  Intravenous  administra- 
tion is  used  chiefly  in  determining  unilateral  function,  as  for  this  ureteral 
catheterization  is  necessary,  and  it  is  desirable  to  shorten  the  period  of  observa- 
tion as  much  as  possible.  Thus  given,  during  the  first  fifteen  minutes  of 
elimination  from  35  per  cent,  to  45  per  cent,  is  excreted,  50  per  cent,  to  65 
per  cent,  during  the  first  half  hour,  and  63  per  cent,  to  80  per  cent,  during 
the  first  hour;  the  observation  is  generally  concluded  at  the  end  of  half  an 
hour,  or  at  the  end  of  fifteen  minutes  if  the  elimination  is  free.  The  ureteral 
catheters  must  collect  all  of  the  urine  secreted;  if  this  cannot  be  done  by 
means  of  flute-tipped  catheters,  an  occluding  Garceau  catheter  must  be  used 
on  one  side,  while  the  urine  from  the  other  side  is  collected  transvesically. 

It  is  difficult  to  state  definitely  in  the  presence  of  what  percentage  it  is 
permissible  to  perform  operations  of  a  serious  nature.  It  would  seem  that 
prostatectomy,  for  example,  is  generally  contra-indicated  by  a  two-hour  elimi- 
nation of  30  per  cent,  or  less,  especially  if  the  second  hour's  elimination  is 
equal  to,  or  greater  than,  that  of  the  first  hour.  For  operations  injuring  or 
removing  one  of  the  kidneys  a  relatively  higher  percentage  should  be  required 
from  the  opposite  organ  than  when  neither  kidney  is  to  be  the  subject  of  opera- 
tive attack. 

Urea  Nitrogen  of  the  Blood. — If  it  be  necessary  to  supplement  the  results  of 
the  tests  of  elimination  by  a  study  of  the  retained  products  in  the  blood,  the  de- 
termination of  the  urea  nitrogen  of  the  blood  is  probably  the  best  and  most 
popular  test  of  retention  due  to  renal  insufficiency.  The  technic  employs  similar 
apparatus  and  the  comiputation  is  made  in  the  same  way  as  for  non-protein  ni- 
trogen, but  the  method  consumes  less  time  and  therefore  may  be  preferable.  Nor- 
mal values  lie  between  10  and  15  mgm.  per  100  c.c.  of  blood.  As  a  rule  the  tests 
of  retention  closely  parallel  the  tests  of  elimination.  There  is  this  alleged  dif- 
ference, the  dye  tests  of  excretion  indicate  the  state  of  kidney  function  for  the 
moment,  whereas  the  nitrogen  retention  tests  are  a  measure  of  the  difference  be- 
tween the  amount  of  waste  nitrogen  produced  by  metabolism  and  the  amount 
eliminated  by  the  kidneys.  Should  either  of  the  dye  tests  show  a  low  output  in 
the  urine,  the  result  should  be  confirmed  by  one  of  the  blood  tests  of  retention. 


EXAMINATION  OF  THE  URINE  23 

Total  Nonprotein  Nitrogen  Determination. — The  determination  of  the 
amount  of  total  nonprotein  nitrogen  in  the  blood  (that  is,  urea  and  other  nitrog- 
enous elements)  has  not  been  made  in  a  sufficiently  large  series  of  cases  to  estab- 
lish its  worth  above  that  of  the  other  tests  described.  As  the  examination  (Folin's 
method  is  the  most  reliable)  can  be  made  only  in  a  well-equipped  laboratory, 
and  there  only  at  the  expenditure  of  considerable  trouble,  the  test  is  not  likely 
to  prove  popular.  However,  when  the  determination  can  be  made  it  affords 
evidence  of  about  equal  value  to  that  given  by  the  other  methods  described. 
In  normal  individuals  the  total  nonprotein  nitrogen  of  the  blood,  as  deter- 
mined by  Folin's  method,  lies  between  15  and  43  milligrammes  per  cubic  centi- 
metre. From  50  to  60  per  cent,  of  this  is  the  ammonia-urea  fraction  (Farr 
and  Austin). 


CHAPTER  III 

CHOICE,  CARE,  AND  STERILIZATION  OF  INSTRUMENTS 

CHOICE  OF  INSTRUMENTS. 

For  the  general  practitioner  who  desires  to  be  so  equipped  that  he  may 
relieve  retention  of  urine  whether  this  be  due  to  spasm,  stricture,  or  enlarged 
prostate,  and  to  recognize  and  treat  the  more  common  conditions  encountered  in 
office  practice,  the  following  equipment  will  suffice: 

Catheters:  Rubber,  Nos.  12,  16,  and  18  F.;  rubber,  elbowed,  Nos.  16  and 
18  F.;  woven,  elbowed,  with  olivary  tip,  Nos.  12  and  16  F.;  woven,  to  screw 
on  woven  filiform.  No.  14  F.;  metal.  Van  Buren  curve.  No.  14  F.;  metal,  "  pros- 
tatic "  curve  (arc  of  circle  of  5  to  S^  inches  diameter),  No.  14  F.;  metal,  Gou- 
ley's  (tunneled  at  tip  for  threading  over  a  filiform  bougie).  No.  12  F. 

Bougies:  Filiform  (whalebone)  with  olivary  tips,  ^  dozen.  Bougies 
a  boule,  woven,  Nos.  12,  16,  and  20  F. 

Sounds:  Van  Buren  or  Otis  curve,  Nos.  12  to  30  F.  (alternate  sizes). 

Meatotome. 

Syringes:  Glass,  holding  ^  to  1  ounce. 

Fountain  syringe,  or  irrigator  (preferably  of  the  Valentine  model). 

Deep  urethral  instillator,  No.  20  F. 

Finger  cots. 

Lubricant. 

The  sizes  of  instruments  are  given  according  to  the  Charriere,  or  French, 
scale.  The  number  indicates  the  circumference  of  the  instrument  in  milli- 
metres. 

The  geni to-urinary  specialist  requires  a  more  extensive  equipment.  Whilst 
each  will  select  instruments  in  accordance  with  his  habitual  or  occasional  needs 
and  his  individual  preferences,  in  addition  to  the  list  given  as  serviceable  to 
the  general  practitioner,  including  a  much  larger  assortment  of  catheters, 
bougies,  and  sounds,  the  following  are  suggested  as  likely  to  be  generally 
helpful  in  both  diagnosis  and  treatment: 

Instruments  Used  in   Examinations 
Urethrometer  (Otis). 
Vesical  stone  searcher. 
Urethroscopes  (see  Chapter  IV). 
Cystoscopes  (see  Chapter  V). 

Ureteral  catheters,  plain  and  impregnated  with  metal  (radiographic,  see 
Chapter  V). 

Battery  or  rheostat  (see  Chapter  V). 
X-ray  apparatus. 

Colorimeter  (Duboscq  or  Hellige). 

Dark-field  substage  for  microscope,  and  illuminator  for  same. 
24 


CHOICE  AND  CARE  OF  INSTRUMENTS  25 

If  the  specialist  has  not  the  facilities  of  an  equipped  laboratory-,  he  may 
also  need  in  his  examination  a  colorimeter,  a  spectroscope,  and  a  polariscope. 

InstrumeriLS  Used  in  Routine  or  Special  Treatment 

Flexible  shot-filled  bougies,  Nos.  10  to  20  F. 

Kollmann  dilator,  with  blades  for  the  anterior  and  posterior  urethra. 

Rectal  electrode. 

Faradic  and  galvanic  batteries. 

Ointment  depositors. 

Apparatus   for  intravenous  medication. 

Syringes  of  various  sizes  (all-glass  or  glass-and-metal  hypodermic  syringes, 
syringes  for  injecting  considerable  quantities  of  fluid  (e.g.,  salvarsan  and  indigo- 
carmin),  syringes  for  filling  the  bladder). 

Knives,  scissors,  forceps,  and  electrodes  for  use  through  urethroscope. 

High-frequency  machine. 

Instruments  for  Operative  Treatment 

Urethrotomes  (Maisonneuve  and  Gerster,  see  Chapter  XIII). 

Urethral  staffs  (grooved  on  convexity  and  side). 

Gorget  (Teale's). 

Prostatectomy  retractors  and  forceps  (Young's  and  Thomas's). 

Prostatic  punch  (Young's). 

Prostatic  incisor  (galvanocautery). 

Stone  forceps. 

Stone  scoop. 

Lithotrites. 

Bigelow's  evacuator. 

Clamps  for  renal  pedicle. 

Usual  operating  instruments. 

The  soft-rubber  catheters  must  be  smooth,  strong,  elastic,  and  not  too 
flexible.  The  ends  should  be  shghtly  conical  (Fig.  2),  though  with  a  dis- 
tinctly rounded  extremity,  rather  than  hemispherical;  the  elbowed  extremity 
is  particularly  desirable  in  prostatic  cases.    They  are  the  instruments  of  choice 


Fig.   2. — Cylindrical  catheter. 

when  the  bladder  is  to  be  either  emptied  or  filled,  since  they  are  the  least 
traumatizing  of  all  urethral  instruments.  Loss  of  elasticity  or  smoothness  is 
an  indication  for  rejection. 

Elbowed  woven  catheters  are,  in  cases  of  prostatic  obstruction,  easier  of 
introduction  than  are  similar  catheters  which  are  straight;  an  olivan,^  tip  still 
further  facilitates  their  passage  (Fig.  3).  Very  narrow  strictures  are  best 
passed  by  a  straight  woven  catheter  screwing  into  a  woven  or  whip  filiform 
bougie  (Fig.  4).  A  woven  catheter  which  has  lost  its  surface  shoifld  be 
rejected. 

The  eyes  of  metal  catheters  should  exhibit  margins  so  smooth  and  de- 
pressed that  the  urethral  mucosa  cannot  be  traumatized  thereby. 


26  GENITO-URINARY  SURGERY 

The  lip  of  the  lumen  of  a  Gouley's  catheter  must  be  smooth  to  avoid  cutting 
either  the  urethra  or  the  filiform,  and  the  aperture  must  allow  free  passage 
of  any  of  the  filiform  bougies  used  in  passing  a  tight  stricture. 

The  filiform  bougies  should  be  of  exactly  equal  length,  free  from  splits 
or  cracks,  and  should  be  capable  of  holding  an  angle  made  by  bending  over 
the  thumb-nail  without  exhibiting  any  surface  break  or  roughening. 

Bougies  a  boule  of  linen  or  silk  web,  with  abrupt,  sharp-edged  shoulders, 
are  the  best.  Metal  instruments  of  similar  shape  are  more  durable  and  are 
more  readily  sterilized.  A  urethrometer  (Fig.  5)  satisfactorily  replaces  these 
intruments. 

Sounds  should  have  smooth,  untarnished  surfaces,  with  a  taper  which 
reaches  full  calibre  before  the  termination  of  the  curved  portion. 

A  glass  container  should  be  used  for  urethral  irrigations,  etc.,  since  failure 
to  keep  it  clean  can  be  readily  detected  and  the  flow  of  its  contents  can  be 


Fig.  3. — Elbowed  olivary  catheter. 
Fig.  4. — Phillips  catheter. 
Fig.  5. — Otis  urethrometer. 


observed.  The  Valentine  handle  for  manipulating  the  urethral  nozzle  and 
controlling  the  flow  of  the  fluid  is  convenient. 

Deep  urethral  instillators,  catheter-like  tubes  with  very  small  lumens, 
threaded  to  screw  on  a  hypodermic  syringe,  are  least  traumatizing  when  of 
intermediate  size.  They  are  used  for  depositing  small  quantities  of  fluid  in  the 
posterior  urethra. 

Each  batch  of  finger  cots  should  be  tested  before  purchase.  They  should 
be  long  enough  to  completely  cover  the  finger,  strong,  and  of  suitable  size. 

The  most  satisfactory  lubricants  are  water-soluble.  Many  such  arc  on 
the  market,  having  as  a  base  substances  such  as  Iceland  moss,  gum  tragacanth, 
and  quince  seeds. 

Bougies,  woven,  filled  with  fine  shot  to  within  one  or  one  and  a  half  inches 
of  their  tips,  particularly  useful  in  the  dilatation  of  small  strictures,  shoi'.ld 
exhibit  extremely  flexible  tips,  that  they  may  easily  follow  an  aberrant  passage 
through  a  stricture. 


CHOICE  AND  CARE  OF  INSTRUMENTS 


27 


Kollmanns  dilators  (Figs.  6  and  7),  now  made  with  a  universal  handle, 
designed  to  treat  the  anterior  and  posterior  portions  of  the  urethra  separately, 
are  more  useful  than  the  models  designed  for  the  simultaneous  treatment  of 
both  portions.  Their  rubber  covers  should  be  large  enough  to  slip  on  easily, 
and  strong  enough  not  to  break. 

Rectal   electrodes    for    prostatic    treatment    should    have    uncovered    metal 


Fig.  6. — KoUmann  anterior  and  posterior  dilators,  with  universal  handle. 

on  the  anterior  surface  only;  electrodes  of  other  forms  (Fig.  8)  may  be  modi- 
fied by  dipping  them  into  melted  paraffin,  the  wax  being  scraped  off  at  the 
desired  point. 

Urethral  ointment  depositors    (anterior)    are  made  in   the  form  of  cones 
(Fig.  9)  to  screw  on  collapsible  tubes  in  which  the  ointment  is  dispensed.     For 


mssmiA; 


Fig.   7. — KoUmann   dilator,  with  cover  applied. 

posterior  applications  an  instrument  with  a  long  curved  nozzle  must  be  used; 
means  must  be  provided,  as  a  threaded  plunger,  for  forcing  the  ointment  through 
the  narrow  lumen  of  the  tube  (Fig.  10). 

Intravenous  medication  should  be  administered  vidth  the  simplest  apparatus 
compatible  with  efficiency  and  safety.  A  burette,  four  feet  of  rubber  tubing, 
and  a  needle  are  required,  the  tube  ending  in  a  teat  which  exactly  fits  the  needle, 
and  being  provided  with  an  occlusion  catch   (Fig.   11).     A  bubble-catcher  in 


28 


GEXITO-URIXARY  SURGERY- 


the  tube  close  to  the  needle,  a  stopcock  in  the  burette,  and  a  stopcock  needle 
to  which  the  rubber  tubing  is  firmly  attached  are  usual  modifications  of  this 
simple  apparatus. 


f^ 


Fig.  8. — ^Rectal  .electrode. 
Fig.  9. — Anterior  ointment  depositor. 
Fig.   10. — Posterior  ointment  depositor. 


--«:|D 


Fig.   11. — Intravenous  apparatus. 

Examining  and  Operating  Table. — The  special  manipulations  for  which  a 
genito-urinary  surgeon's  table  should  be  adapted  are  cystoscopy  and  urethro- 
scopy: otherwise  all  necessary  procedures  can  be  performed  on  any  of  the 
standard  makes  of  tables.  For  cystoscopy,  however,  it  is  convenient  to  have 
the  table  36  inches  high   (Fig.  12),  fitted  with  a  drawer  for  the  reception  of 


CHOICE  AND  CARE  OF  INSTRUMENTS 


29 


irrigation  fluid,  etc.,  and  to  have  stirrups  arranged  to  hold  the  patient's  ex- 
tremities securely  and  comfortably  in  the  most  advantageous  position;  i.e., 
with  the  knees  about  eight  inches  above  the  level  of  the  buttocks  and  the  legs 


Fig.    12. — Manhattan   table,   modified   for   cystoscopy   by   the  addition  of   a   waste-solution   drawer, 
and  suitable  supports  for  the  lower  extremities. 

and  feet  directed  toward  the  floor  (see  Fig.  25  in  Chapter  V).  This  may  be 
accomplished  either  by  means  of  supports  under  the  knees  or  by  means  of  foot- 
pieces. 

STERILIZATION  OF  INSTRUMENTS 

Instruments  composed  entirely  of  metal  or  of  soft  rubber  can  be  sterilized 
without  injury  by  boiling  for  from  one  to  three  minutes  in  water,  or,  better, 
since  this  prevents  tarnishing,  in  sodium  carbonate  solution  (2  per  cent.);' 
this  applies  to  edged  instruments  as  well  as  to  others.  Implements  made 
entirely  of  glass  can  usually  be  boiled  without  breaking,  especially  if  the  glass 
be  thin  and  the  articles  be  completely  submerged.  Glass  of  varying  thick- 
ness may  be  boiled  if  submerged  in  cold  or  lukewarm  water  before  putting 
over  the  fire.  A  sudden  change  from  cold  to  hot  is  less  harmful  than  a  similar 
change  in  temperature  in  the  opposite  direction.  Articles  composed  of  more  than 
one  part,  whether  of  metal  or  glass,  in  which  the  fitting  is  exceedingly  close,  must 
be  taken  apart  before  boiling  to  avoid  distortion  or  breakage. 

Instruments  composed  of  both  glass  and  metal,  as  some  syringes,  may  be 
boiled,  provided  heat  is  applied  gradually. 

Though  woven  instruments  of  the  best  grades  can  be  boiled  a  few  times 
without  injury,   these  instruments  and  cystoscopes  are  better  sterilized   just 


30  GENITO-URINARY  SURGERY 

before  use  by  means  of  cold  antiseptic  solutions  or  by  formaldehyde  gas.  For 
general  purposes  a  5  per  cent,  solution  of  liquor  formaldehyde,  applied  for 
ten  to  fifteen  minutes,  is  the  best.  It  is  essential  that  the  solution  come  in 
contact  with  every  part  of  the  instruments,  and  it  is  therefore  necessary  to 
force  it  through  small  openings  by  means  of  a  syringe.  For  cystoscopes  and 
similar  instruments  solutions  of  phenol  (5  per  cent.)  or  one  of  the  cresols 
(2  per  cent.)  may  be  employed,  but  these  substances  are  ruinous  to  the  sur- 
face of  woven  instruments. 

Formaldehyde  gas  may  be  derived  from  the  official  solution,  or  from  tablets, 
either  by  allowing  them  to  simply  evaporate  or  decompose  in  the  air,  or  more 
rapidly  by  the  application  of  heat.  At  least  twenty-four  hours  should  be 
allowed  for  the  gas  to  act,  and  in  the  case  of  instruments  with  small  lumens, 
as  ureteral  catheters,  even  more  time  is  necessary.  The  method  is  particularly 
applicable  to  the  sterilization  of  urethral  catheters,  that  they  may  be  ready 
for  immediate  use.  A  number  of  "catheterostats"  for  the  storing  of  catheters 
in  the  presence  of  formaldehyde  are  on  the  market.  The  method  is  specially 
useful  for  patients  who  have  to  catheterize  themselves  several  times  a  day. 
By  having  sufficient  catheters  on  hand  to  last  two  days,  and  placing  them 
in  two  receptacles  containing  formaldehyde  vapor,  a  sterile  catheter  is  always 
ready  for  use.  Aside  from  the  time  needed,  the  chief  disadvantage  of  the  method 
is  the  fact  that  unless  the  catheters  are  exposed  to  the  air  for  some  hours 
or  are  washed  with  water  or  boric  solution  sufficient  formaldehyde  adheres  to 
them  to  cause  urethral  irritation. 

CARE  OF  INSTRUMENTS 

Since  it  is  essential  that  urethral  instruments  should  be  perfectly  smooth, 
it  is  necessary  to  keep  their  protective  covering,  nickel  or  varnish,  unimpaired; 
hence  metal  instruments  should  not  be  knocked  together  at  any  time.  This 
is  best  prevented  by  storing  the  instruments  in  drawers  so  shallow  that  but 
one  layer  is  easily  contained;  in  the  case  of  sounds  and  bougies,  it  is  a  con- 
venience to  have  a  wooden  or  metal  rack,  that  each  may  have  its  place  and  be 
easily  found. 

Woven  and  soft-rubber  instruments  may  be  kept  in  contact  with  one 
another  in  long,  narrow  boxes  if  dusted  with  powdered  talc;  otherwise  they 
are  apt  to  adhere. 

Cystoscopes  are  best  kept  in  their  respective  boxes. 

All  instruments,  of  whatever  texture,  should  be  cleansed  with  soap  and 
water  immediately  after  use,  sterilized,  and  carefully  dried.  Tubular  instru- 
ments large  enough  to  permit  the  passage  of  cotton  swabs  should  be  washed 
and  dried  in  this  manner;  those  too  small  for  such  manipulations  should  have 
water  forced  through  them,  and  should  then  be  dried  by  means  of  air  from 
a  pump.  In  the  case  of  such  metal  instruments  as  cystoscopes,  after  their 
sterilization  in  5  per  cent,  formaldehyde  for  fifteen  minutes,  drying  may  be 
facilitated  by  means  of  alcohol  and  ether.  The  bearings  and  joints  of  all 
instruments  should  always  be  lubricated  with  sterile  machine  oil  after  each 
operation;  the  life  of  steel  needles  is  greatly  prolonged  by  a  similar  appli- 
cation. 


CHAPTER  IV 

URETHROSCOPY 

Thanks  to  the  excellence  of  the  modern  urethroscopes  the  visual  examina- 
tion of  the  urethra  is  now  accomplished  with  but  little  discomfort  to  the  patient 
or  trouble  to  the  physician.  This  is  particularly  true  of  the  anterior  portion 
of  the  canal,  which  can  be  inspected  with  so  little  traumatism  that  it  should 
constitute  a  part  of  the  routine  examination  of  cases  of  chronic  urethritis. 
Posterior  urethroscopy  is  more  difficult,  more  likely  to  be  followed  by  compli- 
cating traumatic  inflammation  and  requires  the  use  of  special  urethroscopes; 
hence  it  is  less  frequently  employed. 


ANTERIOR  URETHROSCOPY 

Instruments. — The  popular  anterior  urethroscopes  are  straight  tubes, 
usually  24  or  28  F.  calibre,  fitted  with  obturators  to  facilitate  their  introduction, 
and  provided  with  electric  lamps  mounted  on  long  light-carriers  whereby  the 
source  of  light  is  brought  close  to  the  surface  which  is  being  inspected;  in  some 
instruments,  notably  Young's  urethroscope,  the  light  is  directed  down  the  tube 
from  without.  The  advantage  of  the  former  arrangement  is  that  the  illumina- 
tion is  somewhat  more  brilliant  and  that  the  light  is  not  apt  to  be  displaced 
utiintentionally ;  of  the  latter  that  the  lamp  cannot  become  soiled  by  blood  or 
other  fluid  welling  up  into  the  urethroscope;  the  former  type  is  therefore  better 
suited  to  simple  examinations,  and  the  latter  to  operative  work. 


Fig.  13. — Mark's  anterior  urethroscope,  consisting  of  urethroscopic  tube, 
universal  head  (marked  LUX),  obturator,  light  carrier,  and  operating  and  exam- 
ining   windows. 

Mark's  urethroscope  (Fig.  13)  is  the  one  most  generally  useful  for  ante- 
rior examination.  It  is  so  constructed  that  the  air-distended  urethra  can  be 
inspected  through  a  glass  window  which  closes  the  outer  end  of  the  instrument; 
on  removing  the  window  the  instrument  can  be  used  as  an  ordinary  urethroscope. 

31 


32 


GENITO-URINARY  SURGERY 


If  needful,  applications  can  be  made  to  the  distended  urethra  by  inserting  the 
applicators,  etc.,  through  a  rubber  nipple  in  the  operating  window. 

Technique  of  Examination. — In  addition  to  the  urethroscopes,  with  at 
least  two  working  lamps  for  each,  a  proved  reliable  source  of  electricity,  and 
lubricant,  at  least  a  dozen  wooden  applicators  barbed  at  the  end  and  so  wrapped 
with  cotton  as  readily  to  pass  through  the  lumen  of  the  instrument  should 
be  in  readiness  (see  Fig.  14).  The  patient  may  be  lying  fiat  on  his  back,  or 
in  the  cystoscopic  position  (see  p.  36).  Before  introducing  the  urethroscope 
the  external  meatus,  preferably  the  whole  penis,  should  be  cleansed  with  soap 
and  water  and  a  solution  of  bichloride  of  mercury,  and  the  anterior  urethra 
should  be  irrigated  with  normal  saline  solution. 


Fig.  14. — Table  arranged  for  urethroscopic  examination.  On  the  farther  side  of  the  table 
are  a  basin  for  used  instruments,  a  beaker  containing  eucain  solution,  2  empty  beakers  to  hold 
solutions  for  topical  application,  rubber  tubing  for  the  Buerger  urethroscope,  and  conducting 
cords  for  ,  battery  attachment.  On  the  nearer  side  are  a  basin  of  bichloride  solution,  a 
tube  of.  lubricant,  wire  applicators  tipped  with  cotton,  a  deep  urethral  instillator,  a  Mark 
urethroscope  with  2  anterior  and  1  posterior  tube,  a  Buerger  posterior  urethroscope,  and  a 
bulb  attachment  to  produce  air  dilatation  with  the  Mark  instrument. 


After  testing  the  electric  lamp  and  ascertaining  the  amount  of  current 
necessary  to  secure  the  requisite  illumination,  the  obturator  is  placed  in  the 
tube  selected  (the  largest  that  will  easily  pass  into  the  urethra),  it  and  the 
tube  are  sparingly  lubricated,  and  the  instrument  is  introduced  down  to  the 
bulbomembranous  juncture  by  pressing  on  the  handle  of  the  obturator.  Then, 
steadying  the  hand  holding  the  tube  by  resting  the  wrist  on  the  patient's 
thigh,  the  obturator  is  gently  withdrawn  with  the  free  hand,  rapid  removal 
being  avoided  lest  suction  be  produced.  Any  moisture  present  at  the  end  of 
the  tube  is  now  removed  with  cotton;  the  lamp,  if  not  already  in  place,  is 
introduced,  and  the  current  turned  on. 

The  mucosa  is  inspected  while  slowly  withdrawing  the  tube,  pressing  the 
end  now  against  one  side  of  the  urethra,  now  against  another,  to  more  fully 


PLATE  IV. 


Diverticulum  of 
urethra  (epithelialized 
false  passage). 


Chronic  urethritis. 


Normal    anterior    ure- 
thra (air  distention). 


Normal    verumon- 
tanum. 


Papilloma  of  urethra. 


Granular    patch    of 
chronic  urethritis. 


Enlarged  verumon- 
tanum  displaying  utric- 
ulus  on  summit,  pre- 
ceded by  orifices  of 
ejaculatory  ducts;  on 
each  side  the  orifices 
of  the  prostatic  ducts 
are  visifele. 


Cicatrization  in 
chronic  granular  ure- 
thritis. 


Stricture  of  ante- 
rior urethra,  (subacute 
urethritis). 


URETHROSCOPY 


33 


inspect  individual  portions.  If  it  should  become  necessary  to  reinspect  a 
portion  after  it  has  passed  out  of  the  range  of  vision,  the  obturator  must  be 
inserted  before  the  tube  is  pushed  farther  in,  as  otherwise  the  edge  of  the 
tube  would  traumatize  the  mucosa.  When  air  dilatation  is  used  reinsertion  of 
the  obturator  is  unnecessary,  as  the  urethra  can  be  ballooned  out  sufficiently 
to  permit  passage  of  the  open  tube  without  damage;  if  the  meatus  be  large 
it  is  even  possible  to  introduce  the  instrument  without  making  use  of  the 
obturator  at  all. 

Appearance  of  the  Anterior  Urethra. — The  color  of  the  mucosa  in  the 
anterior  urethra  varies  from  a  rather  bright  red  in  the  bulbous  portion  of  the 
canal  to  a  much  lighter  shade  in  the  portions  nearer  the  meatus  (see  Plate  IV, 


Fig.  is. — Anterior  urethroscopy  with  the  Mark  instrument.  The  penis  is  held  snugly 
about  the  instrument  by  the  thumb  and  forefinger  of  the  operator's  left  hand  to  prevent  the 
escape  of  air  passed  in  through  the  instrument  from  the  bulb  held  by  the  patient. 

Chapter  I).     At  the  margins  of  the  field  there  is  blanching  from  emptying  of 
the  tissues  of  blood  incident  to  pressure  of  the  tube. 

The  surface  of  the  mucosa  should  be  moist  and  glistening.  The  portion 
seen  at  the  end  of  a  simple  urethroscopic  tube  held  exactly  in  the  centre  of 
the  urethra  has  the  shape  of  a  shallow  funnel,  the  dimple  in  the  centre  repre- 
senting the  continuation  of  the  urethral  canal.  This  is  known  as  the  ''central 
figure  of  the  urethra,"  and  its  appearance  is  an  indication  of  the  condition  of 
the  tissues  of  the  urethral  walls.  Normally  the  funnel  is  very  shallow,  and  the 
mucosa  is  thrown  into  from  eight  to  sixteen  radiant  striae  by  the  action  of  the 
surrounding  tissues,  pressing  the  walls  together.  When  from  any  cause  the 
mucosa  and  submucosa  become  thickened,  there  is  a  reduction  in  the  number 
3 


34  GEXITO-URIXARY  SURGERY 

of  striae  and  a  corresponding  increase  in  their  breadth.  Under  such  circum- 
stances, also,  the  funnel  becomes  deepened,  especially  when  traction  is  made 
on  the  glans,  the  urethra  sometimes  standing  open  for  an  inch  or  more. 
Throughout  the  greater  part  of  its  course  the  anterior  and  posterior  walls  of 
the  urethra  are  in  apposition,  the  only  exception  being  in  that  part  lying 
within  the  glans  where  the  lateral  walls  are  in  contact.  In  the  central  figure 
the  walls  do  not,  therefore,  come  together  in  a  point,  but  rather  in  a  furrow 
so  short  that  it  is  difficult  or  impossible  to  tell  its  direction. 

In  health  the  glands  of  the  urethra  are  not  visible,  but  the  mouths  of  the 
follicles  of  ]Slorgagni  can  be  seen  as  small  red  points,  slightly  deeper  in  hue 
than  the  surrounding  mucosa,  ranged  along  the  dorsal  wall  of  the  urethra. 
The\'  neither  gape  open  nor  stand  up  above  the  surrounding  mucosa. 

With  air  dilatation,  the  patient  manipulating  the  inflating  bulb  in  the 
absence  of  an  assistant  (Fig.  15),  the  picture  is  greatly  altered.  The  central 
ligure  disappears  entirel}",  being  replaced  by  a  long,  open  tube  whose  walls 
become  gradually  approximated  in  the  region  of  the  bulbomembranous  junc- 
ture. Xo  striae  are  present,  but  instead  the  walls  are  seen  approximately  in 
the  condition  present  during  the  passage  of  urine.  The  lustre  is  the  same  as 
seen  with  the  simple  tube,  but  on  account  of  the  angle  at  which  the  light 
is  shed  upon  the  walls  it  appears  somewhat  less.  The  color  varies  greatly 
with  the  pressure  of  the  air,  it  being  possible  to  drive  out  the  greater  part 
of  the  blood  so  that  an  activety  inflamed  mucosa  ma}^  appear  paler  than  normal. 
For  this  reason  it  is  ad\isable  to  use  varjdng  degrees  of  dilatation,  and  to 
conclude  the  examination  by  passing  the  instrument  back  into  the  bulb  and 
remo\'ing  the  window  to  examine  the  urethra  during  the  withdrawal  of  the 
instrument  as  through  a  simple  urethroscope. 

Pathological  Changes  in  the  Anterior  Urethra. — Changes  in  the  mucosa, 
its  glands,  and  in  the  submucous  tissues,  and  new  growths  may  be  recognized 
with  the  urethroscope.  The  mucosa  ma}^  be  redder  or  paler  than  normal,  the 
former  in  acute  or  subacute  inflammation,  and  the  latter  in  chronic  conditions, 
especially  in  the  presence  of  submucous  infiltrations.  Inflammation  of  the 
glands  and  follicles  is  indicated  by  red  or  3^ellow  points  on  the  mucosa,  or  by 
distinct  bulging  from  accumulation  of  secretions.  Granular  patches  and  ulcers 
are  not  common  lesions.  Care  must  be  taken,  when  using  simple  urethroscopes, 
not  to  mistake  the  bulging  of  the  normal  mucosa  of  the  bulb  for  the  former 
condition.  When  present  the}^  are  best  recognized  and  treated  through  the 
urethroscope.  Infiltration  of  the  "soft"  variety  is  indicated  by  a  somewhat 
darker  color  of  the  mucosa,  by  a  diminution  of  the  lustre  of  the  surface, 
and  by  a  reduction  in  the  number  of  striae  in  the  central  figure.  As  the  process 
progresses  the  development  of  fibrous  tissue  and  its  contraction  gradually  reduce 
the  vascularit}'  of  the  region,  and  finally  lessen  the  calibre  of  the  canal  so 
that  a  stricture  is  formed.  With  a  simple  urethroscope  this  can  only  be  appre- 
ciated when  it  has  advanced  so  far  that  it  interferes  with  the  passage  of  the 
instrument,  but  with  the  air-dilating  tj^pe  the  slightest  narrowing  can  be  readily 
noted.  Xew-growths.  chiefly  benign,  are  occasionally  encountered,  as  are  calculi 
and  various  foreign  bodies  introduced  into  the  urethra. 


URETHROSCOPY  35 

POSTERIOR  URETHROSCOPY 

Instruments. — A  painful  and  traumatizing  examination  of  the  posterior 
urethra  may  be  made  with  the  straight  tubes  used  for  the  anterior  urethra. 
To  a  less  degree  this  holds  true  of  tubes  with  short  curved  ends,  having  open- 
ings at  the  convexity  or  heel,  the  so-called  Swinburne  tubes.  These  should  be 
reserved  for  applications  (Fig.  16). 

The  best  instruments  for  visual  examination  of  the  posterior  urethra  are 
the  cysto-urethroscope  of  Buerger  (Fig.  17),  McCarthy's  urethroscope,  and  the 


Fig.   16. — Mark's  posterior  urethroscope  (Swinburne  tube). 

Acmi  cystoscope  manufactured  by  the  Wappler  Company.  Of  these  instruments, 
the  two  latter  have  larger  fields  of  vision,  but  the  first  is  least  traumatizing, 
having  a  much  smaller  fenestra,  and  is  the  one  of  choice.  These  instruments 
contain  lens  systems,  and  are  used  with  water  dilatation. 

Technique  of  Posterior  Urethroscopy  (Fig.  18). — When  one  of  the 
water  distention  urethroscopes  is  used,  a  reservoir  with  boric  acid  or  normal  saline 
solution  must  be  provided,  with  small  calibre  rubber  tubing  to  connect  it  with 


aiattjfe'ag 


/ 


Fig.  17. — Buerger's  cysto-urethroscope.  The  white  lines  mark  the  limits  of  direct  illumi- 
nation, while  the  dark  lines  show  the  boundaries^  of  the  visual  field.  Practically  the  field  of 
vision  is  limited  to  the  white  area. 

the  urethroscope.     The  position  of  the  patient  is  the  same  as  for  cystoscopy 
(Figs.  18  and  25). 

Five  minutes  before  beginning  the  examination  the  posterior  urethra  should 
be  anaesthetized  by  an  instillation  of  a  drachm  or  more  of  4  per  cent,  eucain 
or  novocaine.  After  this,  the  amount  of  electricity  needed  for  the  lamp  having 
been  ascertained,  and  the  lenses  cleaned  with  a  piece  of  dry  gauze,  the  instru- 
ment is  introduced  into  the  bladder,  the  contents  of  this  organ  are  evacuated, 
and  its  interior  washed  through  the  sheath  of  the  urethroscope,  the  lens  system 
is  introduced,  the  electrical  connections  are  made,  the  irrigating  fluid  is  started 


36 


GENITO-URINARY  SURGERY 


flowing  from  the  reservoir,  and  the  examination  is  begun.  The  fluid  is  allowed 
to  flow  throughout  the  examination. 

Appearance  of  the  Posterior  Urethra. — The  examination  is  begun  by 
observing  the  contour  of  the  vesical  orifice  by  rotating  the  instrument  at  the 
point  where  the  field  is  bisected  by  the  internal  sphincter.  Normally  the 
orifice  has  an  even  curve,  but  enlargements  of  the  prostate  may  cause  marked 
alterations  in  its  contour  (see  Chapter  V).  The  mucosa  of  the  posterior  urethra 
is  more  vascular  than  that  of  either  the  bladder  or  the  anterior  urethra.  The 
roof  and  lateral  walls  exhibit  no  noteworthy  features;  however,  they  may 
be  the  site  of  pathological  lesions,  and  consequently  should  be  the  subjects  of 
routine  examination. 

The  floor  of  the  prostatic  urethra  is  a  little  redder  than  the  lateral  walls 


Fig.    18. — Posterior   urethroscopy.      Buerger   instrument    inserted,    with   tube   leading    to    reser- 
voir, and  short  tube  attached  for  directing  fluid  to  bucket  below. 

and  roof,  and  contains  the  urethral  crests  culminating  in  the  verumontanum. 
The  crests  are  small  ridges  which  begin  sometimes  on  the  floor  of  the  trigonum 
close  to  the  sphincter,  or  more  often  in  the  urethra.  They  are  from  two  to 
five  in  number,  and  finally  unite  at  the  base  of  the  verumontanum.  This,  the 
most  prominent  feature  of  the  region,  contains  at  its  summit  the  sinus  pocularis, 
on  the  lips  of  which  are  situated  the  orifices  of  the  ejaculatory  ducts,  while 
in  the  sulcus  at  each  side  are  the  openings  of  the  majority  of  the  prostatic 
ducts.  Usually  the  surface  of  the  verumontanum  is  smooth,  but  occasionally 
it  is  irregular  or  bossed  even  in  normal  cases;  it  varies  considerably  in  size. 

The  examination  of  certain  parts  of  the  urethra,  as  the  sulci  at  the  sides 
of  the  verumontanum,  is  sometimes  facilitated  by  stopping  the  flow  of  the  irri- 
gating fluid,  or  even  allowing  a  portion  of  it  to  flow  out  through  one  of  the 
cocks,  thereby  causing  the  mucosa  to  approach  the  lens. 


URETHROSCOPY 


^7. 


Pathological  Changes  in  the  Posterior  Urethra. — The  floor  and  the  roof 
of  the  posterior  urethra  seem  to  be  affected  oftener  than  the  lateral  walls.  In 
the  presence  of  a  considerable  degree  of  inflammation  the  mucosa  is  redder 
than  normal,  and  frequently  appears  roughened;  occasionally  there  is  a  dis- 
tinctly granular  appearance.  Flakes  of  pus  are  often  seen  adhering  to  the 
orifices  of  the  follicles.  Sometimes  only  the  terminal  results  of  inflammation 
are  to  be  seen,  causing  more  or  less  distortion,  especially  of  the.  verumontanum. 
Occasionally  small  cysts  or  papillomata  are  found  in  this  portion  of  the  urethra. 
These  may  be  either  single  or  multiple.  Hypertrophy  of  the  verumontanum 
is  sometimes  so  great  that  it  is  to  be  considered  a  pathological  lesion.  In 
making  such  a  diagnosis  the  changes  in  size  incident  to  erection  of  this  organ 
are  to  be  borne  in  mind. 

TOPICAL  APPLICATIONS  AND  OPERATIONS 

These  are  most  easily  performed  through  one  of  the  simple  tube  urethro- 
scopes, either  with  or  without  air  dilatation.  In  the  latter  case  the  tissues  are 
somewhat  steadied  by  being  put  on  a  stretch,  and  there  is  a  reduction  in  the 
amounr  of  hemorrhage.  The  medicament  most  used  in  topical  applications  is 
silver  nitrate,  either  as  a  strong  solution  or  in  the  solid  form. 

Operative  procedures  may  be  performed  with  knife,  scissors,  rongeur,  cautery, 


Fig.   19. — Electrolytic  needle. 

electrolytic  needle,  or  high-frequency  electrode.  The 
last  named  is  particularly  adapted  to  the  destruc- 
tion of  cysts  and  papillomata,  as  it  can  be  manipu- 
lated through  the  irrigating  urethroscope  in  the  pos- 
terior urethra  without  difficulty. 

In  the  treatment  of  folliculitis  the  electrolytic 
needle  (Fig.  19)  is  the  favorite  implement.  The 
needle  should  be  inserted  into  the  follicle  before  the 
current  is  turned  on.  The  negative  pole  being 
used,  the  current  is  turned  on  slowly,  allowed  to 
flow  for  thirty  to  sixty  seconds,  and  as  slowly  turned 
off,  a  rapid  making  or  breaking  causing  increased 
discomfort.    About  five  milliamperes  are  necessary. 

Shtting  up  infected  follicles  with  a  knife  is  a  less  effective  method  of  treat- 
ing the  same  condition.  The  cutting  must  be  done  at  one  stroke  with  a  thin- 
bladed,  sharp  knife,  as  the  bleeding  from  the  first  incision  is  usually  sufficient  to 
obscure  the  field  of  operation. 


CHAPTER  V 

CYSTOSCOPY 

In  addition  to  simple  inspection  of  the  urinary  bladder  it  is  convenient  to 
include  under  tKe  caption  Cystoscopy  all  those  procedures  into  which  the  cysto- 
scope  enters  as  an  integral  factor.  The  present  chapter  will  therefore  deal  also 
with  such  subjects  as  ureteral  catheterization,  pelvic  lavage,  pyelography,  and 
certain  methods  of  treatment  of  intravesical  lesions. 

CYSTOSCOPES 

The  simplest  cystoscopes  consist  of  straight  tubes,  through  which  the 
bladder  is  inspected  through  an  air  (Kelly)  or  water  (Braasch)  medium.  In 
other  cystoscopes  the  examination  is  made  through  an  optical  system  con- 
sisting of  a  series  of  lenses  whereby  a  wider  and  clearer  view  is  obtained  of  the 
interior  of  the  bladder. 

Of  the  cystoscopes  employing  an  optical  system  there  are  two  varieties,  the 
direct  (in  which  the  field  of  vision  is  in  the  axis  of  the  instrument)  and  the 
indirect  (in  which  the  rays  enter  the  instrument  through  a  window  in  its  side, 
being  deflected  to  the  ocular  by  means  of  a  prism) ;  some  of  the  cystoscopes  of 
the  latter  type  are  so  constructed  that  retrograde  vision  is  attained  by  means 
of  a  movable  prism,  but  the  addition  is  rarely  of  advantage.  In  the  older,  indirect 
cystoscopes  the  image  is  inverted,  while  in  the  newer  instruments  the  natural 
relations  are  maintained,  wherefore  they  are  spoken  of  as  having  "  corrected 
vision;"  in  neither  types  are  the  sides  of  the  image  transposed.  For  most  pur- 
poses a  cystoscope  provided  with  an  indirect  vision  lens  system  is  the  most  useful. 

A  further  advance  in  the  construction  of  cystoscopes  consists  in  the  incor- 
poration of  means  for  the  easy  renewal  of  the  fluid  contained  in  the  bladder. 
"  Irrigation  "  cystoscopes  are  designed  to  permit  constant  change  of  fluid  during 
the  progress  of  the  examination;  the  desired  result  is  not  attained  on  account 
of  the  imperfect  diffusion  of  the  fresh  fluid.  "  Evacuation  "  cystoscopes  are  so 
constructed  that  the  lens  system  can  be  removed,  leaving  the  sheath  in  place  to 
act  as  a  large-sized  catheter  for  the  rapid  emptying  and  filling  of  the  bladder; 
with  these  instruments  then  the  bladder  can  be  thoroughly  cleansed  and  refilled  in 
a  few  moments. 

The  most  serviceable  type  of  cystoscope  has  provision  for  both  irrigation 
and  evacuation;  in  such  an  one  the  lens  system  can  be  removed  for  cleansing 
of  the  bladder,  replaced,  and  the  bladder  filled  through  one  of  the  cocks  pro- 
vided for  the  control  of  the  irrigation,  this  being  more  readily  accomplished  than 
by  the  simple  evacuating  type  of  instrument.  The  only  advantage  of  a  fixed 
optical  system  over  the  removable  type  as  seen  in  the  evacuating  cystoscopes  is 
that  it  is  possible  to  make  such  an  instrument  of  smaller  calibre.  Cystoscopes 
range  in  size  from  12  F.  to  26  F.;  the  usual  size  of  a  cystoscope  with  provision 
for  catheterization  of  the  ureters  is  24  F. 
38 


CYSTOSCOPY 


39 


Operative  Cystoscopes. — Of  the  many  ingenious  devices  allowing  of  intra- 
vesical treatment,  including  snares,  cutting  instruments,  and  divulsors,  Young's 
cystoscopic  rongeur  is  likely  to  prove  of  most  service.  It  is  adapted  to  the 
removal  of  small  calculi  and  other  foreign  bodies,  as  well  as  to  the  biting  off  of 
intravesical  growths.  In  view  of  the  excellent  results  obtained  by  high-frequency 
desiccation,  the  excision  of  vesical  papillomata,  even  for  diagnostic  purposes,  is 
not  advisable. 

Choice  of  Instruments. — The  following  points  should  be  considered  in  the 
selection  of  a  cystoscope: 

A  lens  system  which  gives  a  clear  view  of  the  bladder  wall  without  undue 
loss  of  illumination. 

A  lamp  of  the  ''  cold  "  type,  so  placed  in  the  instrument  that  its  rays  fall 
directly  on  the  whole  field  of  vision,  the  metal  casing  of  the  lamp  hiding  no 
portion  of  the  filament.    It  is  also  important  that  the  lamp  be  as  large  as  possible. 


"^^S^^^P 


Fig.    20. — Brown-Buerger   cystoscope;   showing   convex   sheath    with   catheterizing   telescope    in 
position,  concave  sheath  with  obturator  in  place,  and  obturator. 

A  smooth,  even  surface,  that  the  introduction  of  the  instrument  may  cause 
little  discomfort. 

Simple,  durable  construction,  that  the  instrument  may  be  easily  cared  for 
and  may  not  require  frequent  repair. 

The  number  and  type  of  cystoscopes  required  vary  with  the  needs  of  the 
individual  surgeon;  unfortunately  it  is  not  possible  to  fill  every  requirement 
with  a  single  instrument.  The  instruments  mentioned  below  are  placed  in  the 
order  of  their  importance  to  the  average  surgeon  specializing  in  genito-urinary 
work. 

1.  A  double  catheterizing  cystoscope,  such  as  the  Brown-Buerger  (Fig.  20) 
or  the  F.  Tilden  Brown  (Fig.  21)  instruments.  The  latter  is  supplied  with  both 
direct  and  indirect  vision  telescopes. 

2.  A  simple  examining  cystoscope  of  small  calibre,  such  as  the  Acmi  13  F., 
or  the  Otis  Brown,  15  F.  (Fig.  22),  "examining  and  irrigating  cystoscopes" 
(evacuation  type). 


40 


GENITO-URINARY  SURGERY 


3.  A  cystoscope  capable  of  transmitting  a  Garceau  11  F.  dilating  ureteral 
catheter,  or  other  flexible  instrument  of  similar  calibre,  such  as  Buerger's  convex 
operating  cystoscope  (Fig.  23) ;  as  this  instrument  has  its  lamp  in  the  heel  of  the 
instrument  it  is  possible  to  bring  the  lens  very  close  to  the  bladder  wall,  and  sa 


Fig.  21. — F.  Tilden  Brown  composite  cystoscope;  showing  sheath  obturated  by  the  indirect  exam- 
ining telescope,  and  the  indirect  and  direct  catheterizing  telescopes. 


T'ig.  22. — Otis  Brown  examining  cystoscope. 


Fig.  23. — Buerger  operating  cystoscope. 

to  examine  and  operate  in  contracted  bladders;  the  instrument  can  also  be  used 
in  the  posterior  urethra. 

All  of  the  instruments  mentioned  above  are  so  constructed  that  the  bladder 
can  be  quickly  evacuated  by  withdrawal  of  the  optical  system.  Collectively 
they  fill  nearly  all  the  requirements  of  the  genito-urinary  surgeon;  if  it  is  desired 
to  increase  the  armamentarium,  this  can  be  done  by  adding  instruments  of 


CYSTOSCOPY 


41 


^    ^s^SrSiRref^S^tts 


different  calibres,  aerocystoscopes,  operating  cystoscopes  of  other  patterns,  photo- 
graphic attachments,  etc. 

Electrical  Supply. — The  current  for  the  illumination  of  cystoscopic  lamps 
may  be  derived  from  the  regular  street  current  by  means  of  suitable  reducers  and 
controllers,  from  dry  cell  batteries,  or  from  storage  batteries.  The  first  method 
is  the  most  convenient  and  economical.  Its  disadvantages  are  that  it  is  not 
always  available;  there  is  some  danger  of  grounding,  with  resultant  mild  shocks 
to  the  patient  or  operator,  and  in  case  the  current  is  also  used  for  operating 
dynamos  (for  elevators,  etc.)  it  is  subject  to  annoying  variations,  sometimes 
decreasing  to  a  point  at  which  the  illumination  is  unsatisfactory,  sometimes 
increasing  sufficiently  to  burn  out  the  lamp  in  the  midst  of  the  examination. 

Storage  batteries  are  convenient  for  office  use  in  the  absence  of  connection 
with  the  street  current.  Their  disadvantages  are  their  weight,  making  trans- 
portation difficult,  and  the  necessity  of  having  them  recharged   at  intervals. 

Rheostats  must  be  used  with  storage  batteries  as 
well  as  with  other  sources  of  electricity. 

For  those  who  must  perform  cystoscopies  in 
different  places  a  battery  composed  of  from  six 
to  twelve  dry  cells  is  the  most  convenient  source 
of  supply.  Freedom  from  shocks  is  assured,  and 
the  battery  can  be  easily  transported  from  place 
to  place.  The  chief  disadvantage  is  the  decrease 
in  amperage  caused  both  by  the  performance  of 
work  and  the  passage  of  time,  necessitating  fre- 
.quent  renewal  of  the  batteries,  and  inconven- 
iently halting  examinations  on  account  of  faiUng 
illumination.  Under  such  circumstances  it  is 
sometimes  impossible  to  tell  without  special  ap- 
paratus whether  the  cause  of  an  obscured  field  is 
depreciation  of  the  battery  or  clouding  of  the  fluid  in  the  bladder  by  pus  or  blood. 
For  this  reason  it  is  of  great  advantage  to  have  a  current  indicator  in  the  circuit, 
as  in  the  battery  illustrated  (Fig.  24).  If  the  amount  of  current  required  to 
produce  proper  illumination  be  noted  before  the  cystoscope  is  placed  in  the 
bladder,  decrease  in  the  amount  of  current  flowing  through  the  lamp  can  be 
remedied  by  means  of  the  rheostat  without  removing  the  cystoscope  from  the 
bladder.  Turning  on  more  current  without  the  guidance  of  such  a  device  is 
apt  to  result  in  damage  to  the  lamp.  " 


Fig.     24. — Dry   cell  batter 

with  rheostat  and  ammeter. 


provided 


PREPARATION  OF  THE  PATIENT 

General  Preparation. — Before  examination  all  patients  should  be  put  on  a 
simple  light  diet,  abundance  of  water,  and  for  one  day  before  the  examination 
thirty  to  sixty  grains  of  hexamethylenamine  or  its  equivalent.  Unless  the  bowels 
are  regularly  moved,  an  aperient  (cascara,  podophyllin,  aloin,  belladonna,  and 
strychnia)  is  given  the  night  before,  followed  by  a  sim.ple  enema  some  hours 
before  the  examination  is  made.  A  careful  cleansing  of  the  vagina  is  needful 
in  women. 


42 


GENITO-URINARY  SURGERY 


The  hypersensitive  are  benefited  by  a  suppository  of  the  extracts  of  opium 
(gr.  i)  and  belladonna  (gr.  }^)  given  an  hour  before  examination,  or  still  more 
by  a  hypodermic  injection  of  morphine  sulphate  (gr.  j^  to  ^4)  ^nd  atropine 
(gr.  Vi5o)-    These  drugs  may  interfere  with  the  estimation  of  kidney  function. 

Local  Preparation. — When  practicable,  exploration  of  the  urethra  and 
prostate  should  precede  by  some  days  the  cystoscopic  examination.  This  is 
desirable,  since  it  accustoms  the  patient  to  the  passage  of  urethral  instruments. 
In  some  cases  repeated  instrumentation  may  be  indicated  for  the  establishment 
of  tolerance  of  their  introduction. 

The  immediate  local  preparation  consists  in  the  thorough  cleansing  of  the 
external  genitalia  and  surrounding  region  with  soap  and  water  and  bichloride 
solution;  when  ureteral  catheteriization  is  to  be  performed  the  inner  aspect  of 
the  thighs  should  be  included  in  this  preparation. 

TECHNIQUE  OF  CYSTOSCOPY 

Position  of  the  Patient. — Cystoscopy  is  most  conveniently  performed  on 
a  table  such  as  that  described  on  page  28.  The  position  obtained  (Fig.  25)  with 
such  a  table,  the  one  which  is  most  comfortable  to  the  patient  and  produces  the 
least  distortion  of  the  parts,  permitting  introduction  of  the  cystoscope  with  the 


Fig.  25. — Position  for  cystoscopy. 


greatest  facility,  can  also  be  secured  by  placing  stools  at  each  side  of  the  foot  of 
the  table  to  support  the  patient's  feet. 

When  it  is  necessary  to  do  a  cystoscopy  in  a  patient's  home,  the  examination 
can  be  conducted  on  an  ordinary  table,  or  even  with  the  patient  lying  across 
the  bed. 

Preparatory  Arrangements. — The  following  articles  should  be  in  readiness, 
surgically  clean  (battery,  etc.,  excepted),  and  in  good  working  order: 


CYSTOSCOPY  ■  43 

Battery  or  rheostat  and  cable. 

Cystoscope. 

Ureteral  catheters. 

Syringe,  glass  or  metal,  holding  100  to  200  c.c. 

Syringe,  glass  dressing,  ^  to  1  oz.  capacity. 

Two  small  glass  receptacles. 

Instillator,  with  syringe  of  1  to  4  drachms  capacity,  or 

Tablet  depositor. 

Two  glass  cylinders  or  beakers. 

Six  test-tubes. 

Meatotome. 

Catheters,  rubber,  Nos.  18  and  20  F.  . 

Catheters,  woven,  Nos.  18  and  20  F. 

Sounds,  Nos.  16,  20,  24,  and  26  F. 

Boric  solution,  2  per  cent.,  or  physiological  saline  solution,  warm,  in  per- 
colator (or  fountain  syringe)  equipped  with  tubing  and  nozzle  which  will 
obturate  cystoscope,  and  in  a  basin. 

Local  anaesthetic  (5  per  cent,  eucaine  lactate  or  novocaine). 

Cocaine,  10  per  cent.,  1  drachm  (for  meatotomy  if  required). 

Lubricant. 

Gauze. 

Cotton. 

Sheets  and  towels. 

Solutions  for  local  preparation. 

If  functional  tests  are  to  be  made,  the  drugs  and  syringes  necessary  for 
the  tests  selected. 

If  pyelography  is  to  be  done,  the  silver  preparation  of  choice,  and  syringe 
or  other  apparatus  for  its  injection. 

Mode  of  Procedure, — Cleanse  patient's  genitalia,  and  cover  thighs  and 
abdomen  with  sterile  sheets. 

Irrigate  the  anterior  urethra. 

Place  local  anaesthetic  in  posterior  urethra,  or  in  females  within  the  meatus 
(women  require  less  perfect  anaesthetization  than  men;  frequently  no  anaesthetic 
is  indicated). 

Cleanse  lenses  of  cystoscope,  and  ascertain  the  amount  of  current  required 
to  properly  supply  the  lamp;  the  incandescence  of  the  filament  should  be  such 
that  the  loop  is  not  plainly  seen  when  the  lamp  is  glanced  at  quickly.  After 
the  introduction  of  the  cystoscope  the  current  is  to  be  turned  on  to  the  point 
noted;  increase  beyond  this  point  imperils  the  filament.  Place  catheters  in 
their  places  in  the  cystoscope,  after  demonstrating  them  to  be  patulous  by  forcing 
water  through  them  with  a  syringe.  If  indigocarmin,  etc.,  is  to  be  given,  see 
that  apparatus  for  its  administration  is  assembled.  (These  preparations  are 
made  at  this  time  to  allow  time  for  the  action  of  the  anaesthetizing  drug.) 

Pass  cystoscope  into  bladder.  In  doing  this  the  operator  should  stand 
between  the  patient's  thighs,  draw  the  penis  gently  upward  and  to  his  right 
with  his  left  hand,  insert  the  tip  of  the  thoroughly  lubricated  instrument  into 
the  meatus,  and,  keeping  the  tip  constantly  directed  along  the  urethral  roof,  allow 


44 


GENITO-URINARY  SURGERY 


the  cystoscope  to  slowly  pass  into  the  urethra  (Fig.  26),  largely  by  its  own 
weight.  When  the  tip  of  the  instrument  has  reached  the  bulb  the  fingers  of 
the  left  hand  should  be  placed  beneath  the  scrotum  (Fig.  27),  so  as  to  guide 
the  tip  into  the  membranous  urethra,  while  the  ocular  end  of  the  instrument  is 
lowered  till  the  cystoscope  is  parallel  with  the  table  and  pushed  gently  upon 
till  the  tip  is  felt  to  pass  over  the  prostate  into  the  bladder.  The  obturator  is 
then  removed,  the  urine  evacuated,  and  the  bladder  irrigated  repeatedly  through 
the  sheath  of  the  cystoscope  by  means  of  a  fountain  or  piston  syringe  till  the 
return  fluid  appears  perfectly  clear  when  examined  by  transmitted  light.     The 


Fig.  26. 


Fig.  2  7 


Fig.  26. — Introduction  of  cystoscope.  The  penis  is  drawn  upward  and  the  instrument 
allowed  to  slip  through  the  anterior  urethra  by  its  own  weight.  Tne  examiner  is  standing  at 
the  patient's   side  so   as   not  to  obstruct   the  view. 

Fig.  27. — Introduction  of  cystoscope.     The  fingers  of  the  left  hand  are  guiding  the  instrument  into 

the  membranous  urethra. 

bladder  is  then  filled  with  solution  (boric  or  physiological  saline,  150  c.c.  in  men 
and  200  c.c.  in  women),  or  less  if  these  quantities  cause  discomfort,  and  the 
optical  system  inserted,  or,  if  the  cystoscope  is  furnished  with  pet  cocks  for  the 
control  of  the  bladder  medium,  the  telescope  may  be  inserted  before  filling  the 
bladder.  (The  foregoing  description  relates  particularly  to  cystoscopes  of  the 
evacuation  type.  In  the  case  of  cystoscopes  with  fixed  optical  systems  the  patient 
must  first  be  catheterized,  the  bladder  irrigated,  and  the  fluid  injected  before 
the  introduction  of  the  cystoscope.  If  the  urine  be  perfectly  clear  this  may  be 
used  as  the  medium  for  the  examination,  in  which  case  the  cystoscope  is  intro- 
duced without  Dreliminan^  catheterization.') 


CYSTOSCOPY  45 

The  examiner  now  seats  himself  on  a  stool  of  convenient  height,  makes  the 
electrical  connections,  and  proceeds  with  the  examination.  This  is  best  conducted 
after  a  regular  routine,  the  one  suggested  being  anterior  wall,  right  side,  apex, 
left  side,  posterior  wall,  and  base.  The'  different  portions  are  brought  into  view 
by  varying  the  depth  of  insertion  into  the  bladder,  rotating  the  cystoscope  on 
its  longitudinal  axis,  and  by  moving  the  ocular  from  side  to  side  and  up  and 
down  so  far  as  the  comfort  of  the  patient  will  permit.  Care  must  be  taken 
not  to  traumatize  the  vesical  mucosa,  and  especially  not  to  allow  the  lamp  to 
remain  on  any  one  spot  for  more  than  a  few  seconds,  for  fear  of  producing  a 
burn.  Before  concluding  the  examination  the  contour  of  the  urethral  orifice 
should  be  observed  by  holding  the  cystoscope  so  that  the  field  is  bisected  by 
the  margin  of  the  orifice,  which  is  thus  seen  in  profile,  and  rotating  the  instrument. 

The  base  and  vesical  neck  are  the  most  frequent  sites  of  pathological 
conditions. 

At  the  conclusion  of  the  examination  the  electrical  connections  are  broken, 
the  cystoscope  is  turned  so  that  its  beak  points  upward,  the  bladder  is  emptied 
by  the  withdrawal  of  the  optical  system  and  the  obturator  placed  in  position 
(if  the  cystoscope  is  of  the  evacuation  type),  and  the  instrument  is  withdrawn, 
reversing  the  steps  of  its  introduction. 

The  whole  examination  must  be  conducted  with  the  greatest  gentleness. 
Each  movement  of  the  cystoscope  should  be  as  small  as  circumstances  will  permit, 
and  should  be  made  in  a  slow,  steady,  purposeful  manner,  thereby  causing  the 
least  possible  discomfort  and  inspiring  confidence  in  the  patient.  Rapid  breath- 
ing through  the  open  mouth  often  seems  to  relax  spasm,  and  centres  the  patient's 
attention  on  another  portion  of  his  body. 

A  strict  aseptic  technique  should  be  pursued  when  doing  ureteral  catheriza- 
tion;  mere  cleanliness,  with  care  to  avoid  touching  the  intra-urethral  portion 
of  any  instrument,  is  sufficient  in  the  performance  of  simple  cystoscopy. 

In  learning  the  use  of  the  cystoscope  the  surgeon  must  first  teach  himself 
to  bring  closely  into  view  every  portion  of  the  inner  surface  of  the  bladder.  The 
phantom  bladder,  cadavera,  and  sexual  neurasthenics,  who  are  often  benefited 
by  prolonged  and  painful  manipulation,  offer  the  best  opportunities  for  this 
training.  Finally  comes  the  right  interpretation  of  what  is  seen,  requiring  a 
wide  clinical  experience.  In  the  hands  of  one  without  experience  the  cystoscope 
becomes,  in  most  cases,  simply  a  surgical  toy.  The  experienced  cystoscopist 
may  be  expected  to  determine  the  presence  or  absence  of  tumors,  stones,  foreign 
bodies,  diverticula,  and  ulcerations,  the  extent  and  character  of  a  cystitis,  the 
condition  of  the  ureteral  orifices,  the  nature  of  urinary  obstruction  at  the  vesical 
orifice,  the  secretory  activity  of  each  kidney,  and  the  source  of  blood  or  pus 
in  the  urine.  Furthermore,  in  conjunction  with  the  Rontgen  rays,  ureteral 
catheterization,  and  the  injection  of  a  silver  solution,  hydronephrosis  and 
enlargements  of  the  renal  pelvis  can  be  detected.  As  a  therapeutic  agent  the 
cystoscope  is  used  in  performing  lavage  of  the  renal  pelvis,  in  the  dilatation  of 
strictured  ureters,  in  the  removal  of  ureterocystic  and  small  vesical  calculi, 
and  in  the  treatment  of  vesical  growths  with  the  high-frequency  current. 


46 


GENITO-URINARY  SURGERY 


NORMAL  CYSTOSCOPIC  APPEARANCE 


The  mucosa  of  the  normal  bladder  is  straw-yellow  in  color,  displaying  pink 
tints  here  and  there,  with  arborescent  vessels  upon  its  surface  and  slight  but 
distinct  trabecular  Depression  of  the  shaft  of  the  cystoscope  and  half  rotation 
show  the  base  and  the  trigonum;  at  the  posterior  angles  of  the  trigonum  are  the 
ureteral  orifices,  each  appearing  as  a  depression  or  slit  placed  in  a  little  ridge  of 
mucous  membrane.     At  intervals  of  from  ten  to  sixty  seconds,  or  more,  not 

(I'Y) 


^>P 


Fig.  28. — Urethral  orifice  in  the  male  as  seen  through  indirect  inverted  image  cysto- 
scope. I.  Prostate  normal.  II.  Bilateral  enlargement  of  prostate.  III.  Median  lobe  hyper- 
trophy. IV.  Hypertrophy  of  median  and  both  lateral  lobes.  V.  Same  as  IV,  but  with  lobes 
confluent.      (After    Young.) 

synchronously,  these  ureteral  orifices  gape  and  discharge  a  swirl  of  urine.  Cross- 
ing the  upper  portion  of  the  trigonum  and  forming  its  base  the  interureteric  ridge 
is  characterized  by  a  distinct,  often  abrupt,  transition  of  color  from  the  straw- 
yellow  of  the  general  bladder  cavity  to  the  pink  or  red  of  the  trigonum.  This 
ridge  when  traced  laterally  leads  to  the  ureteral  orifices.  Occasionally,  in  place 
of  the  ridge  there  is  a  distinct  conical  projection  marking  the  ureteral  orifice, 
exhibiting  a  motion  of  recession  and  protrusion.     Failure  to  find  the  ureters  in 


CYSTOSCOPY  47 

the  healthy  bladder  is  generally  due  to  incomplete  dilatation  of  this  viscus,  the 
openings  of  these  ducts  being  concealed  in  the  folds  of  the  vesical  mucosa,  and 
appearing  when  these  folds  have  been  obliterated  by  the  proper  amount  of 
vesical  distention.  In  case  air  has  entered  the  bladder  during  the  preliminary 
washing  or  injection,  it  forms  a  round,  movable,  shining  bubble,  from  the  convex 
surface  of  which  the  cystoscopic  lamp  is  reflected. 

It  is  possible  to  mistake  for  a  tumor  the  projection  of  mucous  membrane 
sometimes  seen  about  the  ureteral  orifice.  The  position  of  the  projection  and 
the  intermittent  jets  of  urine  should  prevent  such  an  error.  The  rugae  of  col- 
lapsed bladders  have  been  mistaken  for  papillomata;  a  further  injection  should 
make  the  nature  of  the  projection  sufficiently  clear. 

In  the  female  due  allowance  must  be  made  for  the  effects  of  the  encroachment 
of  an  anteflexed,  anteverted,  pregnant,  or  fibroid  uterus,  or  of  pelvic  tumors, 
which  may  greatly  alter  the  contour  of  the  bladder  wall. 

Appearance  of  the  Urethral  Orifice  in  the  Male 

The  determination  of  the  conformation  of  the  urethral  orifice  is  of  value  for 
the  recognition  of  the  different  forms  of  prostatic  hypertrophy.  The  examination 
is  made  by  withdrawing  the  cystoscope  till  the  field  is  bisected  by  the  margin 
of  the  orifice,  and  then  rotating  the  instrument.  The  normal  orifice  gives  the 
picture  shown  in  Diagram  I  of  Fig.  28,  the  light  area  representing  the  illuminated 
bladder,  the  dark  the  urethral  mucosa.  If  one  or  more  of  the  lobes  of  the  prostate 
become  enlarged,  protrusions  into  the  bladder  are  produced,  the  limits  of  the 
swellings  being  marked  by  the  presence  of  fissures,  into  which  the  mucosa  dips. 
The  fissures  are  most  plainly  seen  when  the  examination  is  made  with  a  cystoscope 
of  comparatively  small  calibre,  so  that  the  lens  can  be  carried  some  distance 
from  the  side  of  the  urethra  examined.  The  cystoscopic  appearances  of  the 
four  commonest  forms  of  prostatic  hypertrophy  are  shown  in  Fig.  28.  The  deep 
anterior  and  posterior  fissures  caused  by  enlargement  of  the  lateral  lobes  are 
shown  in  II;  in  III  is  shown  enlargement  of  the  median  lobe;  in  IV  the  appear- 
ance of  enlargement  of  the  median  and  lateral  lobes,  when  they  remain  distinct 
one  from  the  other;  while  V  represents  the  appearance  of  bilateral  and  median 
enlargement  when  the  three  lobes  form  a  confluent  mass. 

PATHOLOGICAL  APPEARANCES 

Blood  in  the  bladder  is  sometimes  a  source  of  error.  When  deposited  on 
the  base  of  a  normal  bladder  it  may  present  the  appearance  of  a  severe  subacute, 
chronic,  or  ulcerative  cystitis.  Hemorrhage  beneath  the  mucous  membrane 
causes  the  formation  of  a  yellow  or  brownish,  partly  translucent,  projecting 
tumor,  not  unlike,  papilloma.  The  diagnosis  will  be  suggested  by  a  preceding 
trauma,  such  as  a  recent  cystoscopy,  and  the  presence  of  blood-infiltration  and 
discoloration  of  the  surrounding  mucous  membrane. 

In  the  acutely  or  chronically  inflamed  bladder  the  rugse  may  closely  simulate 
papillomata,  particularly  if  the  inflammation  is  localized  in  one  portion  of  the 
bladder,  as  is  sometimes  the  case.  Fenwick  describes  as  one  of  the  appearances 
of  certain  forms  of  chronic  cystitis  a  polyhedral  or  rectangular  quilting  of  the 


48  GENITO-URINARY  SURGERY 

bladder,  with  projections  between  the  seams  of  swollen,  almost  translucent, 
mucous  membrane,  presenting  the  appearance  of  a  patch  x)f  gelatinous  polyps. 
A  similar  condition  at  the  base  may  produce  small  conical  projections,  or  these 
may  be  caused  by  dilated  mucous  glands  or  vesicular  inflammation.  The  vesicles 
formed  are  round,  translucent,  and  small,  from  the  size  of  a  pin-head  to  that 
of  a  shot,  and  are  especially  numerous  over  the  trigonum.  The  condition  is 
Jmown  as  bullous  oedema  (see  Plate  V,  J). 

Acute  Cystitis. — In  acute  cystitis  the  mucous  membrane  is  intensely  red, 
swollen,  and  elevated  (puffy).  Flakes  of  fibrin  may  be  seen  here  and  there. 
Individual  larger  blood-vessels  appear  dilated,  but  the  fine  reticulum  of  small 
vessels  may  be  invisible  in  the  general  oedema.  The  ureteral  eminences  are  difficult 
to  recognize  on  account  of  the  general  swelling.  There  may  in  severe  cases  be 
membranous  exudate. 

Chronic  Cystitis. — In  chronic  cystitis  the  inflammation  of  the  vesical 
mucous  membrane  may  be  diffuse  or  localized.  The  diffuse  will  appear  as  general 
redness,  always  more  marked  about  the  trigonum  and  orifices  of  the  ureters. 
The  localized  may  show  patches  of  intense  redness,  excoriations,  fissures,  and 
linear  ulcers.  In  addition  there  may  be  noted  in  cases  of  long-standing  vesical 
ulceration  areas  of  contraction,  due  in  part  to  cicatrices,  in  part  to  muscular 
li3^ertrophy. 

The  localized  patches  of  inflammation  are  observed  in  about  four-fifths  of 
the  cases  of  cystitis  (Garceau). 

There  may  rarely  be  noted  small  red,  shiny  granulations,  such  as  are  observed 
on  other  mucous  membranes.  The  lymphatic  nodules  may  be  visible  as  small, 
slightly  elevated,  whitish  translucent  bodies  resembling  sago  grains  located 
beneath  the  mucous  coat  which  covers  them.  The  whole  surface  may  present 
a  ribbed  appearance  from  bladder  hypertrophy.  Various  combined  lesions  are 
common.  Diffuse  inflammation,  excoriation,  ulceration,  patches  of  contraction, 
and  hypertrophy  exist  together.  In  all  forms  of  cystitis  the  severest  lesions  are 
located  on  the  posterior  wall  and  trigonum. 

In  women  the  trigonum  is  almost  invariably  the  site  of  a  chronic  granular 
inflammation,  quite  red  but  insensitive  (cystitis  colli  feminis). 

Cystitis  Cystica. — In  cystitis  cystica,  a  form  of  chronic  hyperplastic  cystitis, 
the  mucous  membrane  appears  studded  with  small  nodules  (Plate  V,  h).  These 
small  nodular  elevations  of  the  mucosa  are  due  to  isolated  islands  of  epithelium 
lying  m  the  subepithelial  connective  tissue,  having  been  form.ed  from  hyper- 
plastic columns  of  the  overlying  epithelium.  After  separation  they  undergo 
cystic  degeneration,  having  at  first  a  clear  mucoid  and  later  a  colloid  content. 
Circumscribed  areas  of  dense,  inflammatory,  cellular  infiltration  are  commonly 
present  in  the  submucosa.  The  condition  must  not  be  confounded  with  cystitis 
colli  granulans,  bullous  oedema,  or  miliary  tuberculosis  of  the  bladder.  Car- 
cinomatous degeneration  is  often  the  terminal  condition. 

Ulcerative   Cystitis. — Vesical  ulceration  may  destroy  the  whole   of  the 
mucous  membrane  in  patches,  revealing  a  smooth,  glistening,  pyogenic  membrane, 
with  white  lines  of  scar-tissue  or  granulation  surface.     Ulceration  is  most  fre- 
quently seen  on  the  posterior  wall  and  within  the  trigonum  at  its  upper  part. 
Nontuberculous  ulceration  presents  lesions  generally  quite  uniform  in  contour, 


PLATE  V. 


Anterior  bladder-wall,  with  air 
bubble. 


Normal  ureteral  orifice. 


Trabeculation  of  the  bladder. 


Indigocarmin  coming  from 
ureter. 


Catheter  entering  normal 
ureter. 


Double  ureteral  orifice  of 
bifurcated  ureter. 


Cystitis  cystica. 


Shell  of  inspissated  pus  sur- 
mounting ureteral  orifice  (case 
of  pyonephrosis). 


Ulcerating  gumma 
(Engelmann). 


Bullous  cedema  of  vesical 
trigone  (Rumpel). 


Tuberculous  ureteral  orifice 
(case  of  renal  tuberculosis). 


Vesical  calculi. 


CYSTOSCOPY  49 

dirty  yellow  in  color,  commonly  about  the  size  of  a  dime,  and  placed  at  or  near 
the  ureteral  orifices.  Its  edges  are  slightly  raised,  undermined,  and  surrounded 
by  a  pale  anaemic  zone,  set  in  the  deeply  injected  mucous  membrane.  This  must 
be  distinguished  from  the  ulcer.  In  contrast  to  the  tuberculous  lesion,  it  seldom 
extends  deeply  into  the  underlying  tissue,  though  it  may  manifest  such  a 
tendency.  The  base  is  of  a  yellow  or  yellowish-white  color  and  usually  smooth, 
though  occasionally  necrotic  shreds  may  be  noted  on  the  surface.  The  ulcers 
are  usually  multiple  to  the  extent  of  two  or  three  lesions,  though  they  may  be 
single;  they  occasionally  are  very  numerous,  and  show  a  tendency  to  coalesce, 
resulting  in  great  destruction  of  the  mucous  surface,  and  presenting  a  smooth, 
glistening,  pyogenic  membrane  with  intermingled  areas  of  scar-tissue  showing  as 
white  lines,  with  red  patches  where  the  inflamed  mucous  surface  is  still  intact. 

Traumatic  ulcers  result  from  the  irritation  of  large  or  rough  vesical  calculi 
or  from  the  trauma  of  childbirth. 

Rare  causes  of  vesical  ulceration  are  thrombosis,  syphilis,  and  trophic  nerve 
lesions.  Thrombotic  and  syphilitic  ulceration  are  absolutely  non-characteristic 
in  cystoscopic  appearance. 

Vesical  Tuberculosis. — In  the  beginning  {i.e.,  before  ulceration  has  oc- 
curred), miliary  tubercles  appear  as  grayish,  round  elevations  surrounded  by 
hyperasmic  areas.  These  by  coalescence  and  caseation  form  the  ulcer.  This  is 
generally  superficial,  circular  in  shape,  uneven  in  contour,  dirty  yellow  in  color, 
and  commonly  about  the  size  of  a  dime.  Its  edges  are  slightly  raised,  under- 
mined, and  surrounded  by  a  pale  anaemic  zone,  set  in  the  deeply  injected  mucous 
membrane. 

When  sharply  outlined  ulcers  develop,  the  diagnosis,  in  the  absence  of  an 
acute  or  a  chronic  cystitis,  is  not  difficult.  When  there  are  general  infiltration 
and  thickening  of  the  surrounding  mucosa,  and  especially  when  there  is  papillary 
outgrowth,  great  ca.re  should  be  exercised  in  forming  an  opinion  as  to  the  tuber- 
culous nature  of  the  lesions  from  their  appearance  through  the  cystoscope. 

Some  of  the  most  puzzling  lesions  are  the  tuberculous  granulomata,  papil- 
lomatous outgrowths  usually  situated  on  the  base  or  posterior  wall.  These  granu- 
lomata may  reach  considerable  dimensions,  even  as  much  as  three  centimetres 
in  diameter,  and  with  a  similar  elevation.  They  may  be  single  or  multiple,  and 
have  no  characteristic  form. 

The  ureteral  orifice  may  be  cedematous  and  pouting,  may  be  eroded,  or  may 
have  the  appearance  of  a  pipe  hole.  As  a  rule,  the  side  of  the  bladder  on  which 
the  affected  kidney  lies  is  the  site  of  the  more  severe  lesions,  but  the  reverse  is 
true  in  a  sufficient  percentage  of  cases  to  rob  the  observation  of  most  of  its 
diagnostic  value. 

Parasitic  Ulcers. — Bilharz,  many  years  ago,  first  directed  attention  to  a 
parasite,  the  Distoma  hccmatobia  cegyptica,  producing  an  urological  affection 
endemic  in  Egypt.  The  vesical  lesions  are  characterized  by  thrombotic  areas 
due  to  the  implanted  eggs  of  the  parasite,  which  later  undergo  ulceration  with 
the  production  of  dark  red  or  brown  blood  coagula  surmounting  the  small  ulcers, 
imparting  an  irregular  sandy  appearance  to  the  mucosa. 

Diverticula. — These  may  be  either  congenital  (Fig.  29)  or  acquired.    The 
former  are  recognized  by  their  smooth,  rounded  orifices  in  contrast  to  the  rather 
4 


so  GENITO-URINARY  SURGERY 

irregular  openings  surrounded  by  trabeculated  bladder  wall  found  in  the  acquired 
t)^e.  These  latter  structures  are  found  in  patients  with  urinary  obstruction, 
and  are  due  to  a  pushing  out  of  the  bladder  wall  between  bundles  of  muscle. 
Diverticula  of  either  type  may  be  single  or  multiple,  and  may  be  either  quite 
small  or  of  considerable  size.  Their  imperfect  drainage  tends  to  the  development 
of  diverticulitis. 

Cystoscopy  is  the  most  satisfactory  method  of  demonstrating  the  existence 
and  location  of  vesical  diverticula  and  fistulse, 

Cystoscopic  Diagnosis  of  Vesical  Tumors. — Provided  that  it  is  possible 
to  manipulate  the  cystoscope  as  freely  as  desired,  and  that  hemorrhage  is  not 
too  profuse,  it  is  usually  possible  to  determine  whether  or  not  a  tumor  is  present; 
the  nature  of  the  tumor  cannot  be  so  easily  recognized  even  to  the  extent  of 
differentiating  between  the  benign  and  the  malignant. 

The  most  important  points  to  be  determined  in  regard  to  a  tumor  are  its 

location,  size,  whether  single  or  multiple, 
and  if  possible  its  nature.  All  of  these 
points  are  of  great  moment  in  determin- 
ing upon  the  mode  of  treatment,  whether 
this  shall  be  conducted  by  means  of  the 
cystoscope,  or  whether  partial  or  com- 
plete cystectomy  shall  be  performed  and 
by  what  route  (extra,  or  transperitoneal). 
Certain  tumors,  as  the  myomata  and 
fibromata,  unfortunately  rare,  and  ap- 
pearing as  rounded  masses  covered  with 
normal  mucosa,  can  be  readily  diagnosed 
as  benign.  The  tumors  of  a  papillary 
character — and  nearly  every  kind  of  vesi- 
cal tumor  may  be  covered  with  a  villous 
Fig.    29.— Congenital    diverticulum    of   the      growth — are  Icss  casily  dlsposcd  of.  Often 

anterior  blaaaer  wall.  "  j  sr 

parts  of  them  are  benign,  as  the  margins 
of  the  growth,  while  other  portions,  especially  the  base,  show  malignant  degenera- 
tion on  microscopic  examination. 

A  tentative  diagnosis  of  a  benign  neoplasm  may  be  made  when  evidence 
of  infiltration  of  the  bladder  wall  at  the  base  of  the  tumor  is  wanting.  Judged 
by  this  criterion,  many  malignant  tumors,  especially  papillomata  in  the  early 
stages  of  malignant  degeneration,  will  be  placed  in  the  benign  class,  but  the 
results  of  treatment  by  the  high-frequency  current,  conducted  through  the 
cystoscope,  are  so  much  better  than  those  obtained  by  operative  measures  in 
the  case  of  such  growths  as  benign  papillomata,  and  the  treatment  is  so  much 
simpler  and  less  terrifying  to  the  patient,  that  the  mistaken  diagnosis  is  justifiable 
pending  the  trial  of  high-frequency  treatment. 

Mistakes  in  the  diagnosis  of  tumor  are  sometimes  caused  by  the  following 
conditions: 

The  bulgins!  of  extravesical  masses  into  the  bladder  (as  enlargements  of 
the  prostate,  the  uterus,  or  uterine  tumors,  etc.),  especially  when  surmounted 
by  bits  of  blood-clot  or  flakes  of  pus. 


CYSTOSCOPY  51 

Enlarged  rugse,  the  subjects  of  well-marked  inflammation,  may  be  so  promi- 
nent when  the  bladder  is  partially  distended  as  to  result  in  a  mistaken  diagnosis. 

Calculi  coated  with  pus  and  mucus,  especially  when  partially  encysted,  are 
sometimes  the  causes  of  mistakes. 

URETEROSCOPY 

Diseased  conditions  of  the  kidneys  and  ureters  are  frequently  indicated  by 
the  appearance  of  the  ureteral  orifices.  Even  in  health  these  structures  vary 
greatly  in  appearance.  Typically  they  are  small  slits,  placed  at  the  ends  of  the 
interureteric  ridge;  unfortunately  the  ridge  is  not  a  constant  structure,  as  when 
present  it  forms  a  useful  guide  to  the  orifices.  The  relation  of  the  ureteral 
orifices  to  that  of  the  urethra,  the  three  lying  at  the  angles  of  the  trigonum,  the 
lines  connecting  them  forming  an  equilateral  triangle,  with  sides  of  about  two 
centimetres,  also  affords  a  means  for  their  location.  When  one  orifice  has  been 
located  (with  an  indirect  vision  cystoscope)  the  other  can  usually  be  found  by 
rotating  the  instrument  90  degrees  across  the  base  of  the  bladder.  In  atypical 
cases  the  orifices  may  be  very  small  or  larger  than  normal;  they  may  also  be 
situated  at  unequal  distances  from  the  urethra.  When  otherwise  invisible  they 
can  sometimes  be  brought  into  view  by  pressure  from  the  rectum  or  vagina.  The 
injection  intravenously  or  intramuscularly  of  a  dye,  as  indigocarmin,  and  the 
observance  of  its  elimination  from  the  ureteral  orifices  serve  both  to  locate  orifices 
difficult  to  see  and  also  the  relative  activity  of  the  functions  of  the  respective 
kidneys.    This  procedure  is  called  chromoureteroscopy,  or  chromocystoscopy. 

The  points  to  be  noted  in  observing  the  ureteral  orifices  are  their  number  (indic- 
ative of  the  number  of  ureters) ,  their  general  appearance  and  that  of  the  surround- 
ing mucosa  (whether  hypersemic  or  pale,  large  or  small,  of  normal  or  distorted 
outline,  the  presence  or  absence  of  oedema,  and  whether  actively  contractile  or  im- 
mobile) ,  and  the  nature  of  the  urinary  efflux.  Hyperaemia,  distortion,  and  oedema 
are  specially  valuable  as  betokening  disease  of  the  corresponding  kidney  or  ureter, 
as  infection,  neoplasm,  or  calculus,  especially  one  low  down  in  the  ureter.  Ureteral 
orifices  w^hich  are  immobile  and  stand  open,  the  so-called  "golf-hole"  orifices,  indi- 
cate an  atonic  condition  of  the  ureter;  when  inflamed  they  are  said  to  indicate  pye- 
lonephritis. The  spurts  from  diseased  kidneys  commonly  occur  at  shorter  and  less 
regular  intervals,  and  are  less  voluminous  than  are  those  from  healthy  organs. 

URETERAL  CATHETERIZATION 

The  purposes  of  this  procedure  are:  (1)  To  determine  whether  both  kidneys 
exist  and  their  relative  function.  (2)  To  secure  the  urine  from  each  kidney 
separately,  in  order  to  determine  the  source  of  such  products  as  pus,  blood, 
epithelium,  bacteria,  and  crystals.  (3)  To  recognize  and  locate  (sometimes  in 
conjunction  with  the  X-rays)  such  obstructive  conditions  as  torsion  and  bending 
of  the  ureters,  valvular  folds,  calculi,  stricture,  and  ureteral  fistula,  to  differentiate 
between  shadows  cast  by  phleboliths  and  those  of  ureteral  calculi,  and  to  deter- 
mine the  size  and  shape  of  the  kidney  pelvis.  (4)  To  dilate  the  normal  or 
strictured  ureter  to  facilitate  the  passage  of  urine  or  calculi.  (5)  To  medicate 
the  ureter  or  kidney  pelvis.     (6)   To  drain  the  kidney. 

Ureteral  Catheters. — Catheters  vary  in  calibre,  in  the  shape  of  their  tips, 
and  in  their  surface  markings  (Fig.  30).  The  usual  size  is  No.  6  F.;  7  F.  is 
so  large  that  it  often  traumatizes  unnecessarily,  while  5  F.,  except  in  very  small 


52  GENITO-URINARY  SURGERY 

ureters,  permits  too  great  an  amount  of  urine  to  pass  beside  it.  The  generally 
useful  tip  for  ureteral  catheters  is  the  olivary,  with  at  least  two  openings  on  the 
sides;  for  the  collection  of  urine  in  determining  kidney  function  the  "  flute  " 
or  "■  whistle  "  tip  catheters,  with  openings  on  the  ends  and  sides,  are  preferable. 
The  catheters  are  also  supplied  either  in  solid  colors  or  graduated  in  centimetres 
by  means  of  alternate  bands  of  different  hues,  so  that  the  examiner  may  tell  the 
depth  to  which  the  catheter  has  been  inserted  into  the  ureter,  thereby  aiding 
him  in  the  location  of  obstructions.  Catheters  impregnated  with  a  metal  or 
metallic  salts  are  made  for  use  in  skiagraphy. 


^s=i^''   •   saSi^ Basi  '  ^TmW-       •TiSMgT°^=^ 


-y«™^w,  ■—■■~~"~' -Hi—rill^  ■ 


Fig.  30. —  Types  of  ureteral  catheters.     The  one  illustrated  at  the  bottom  exhibits  a  long  taper, 
and  is  intended  for  dilating  the  ureteral  orifice. 

Technique  of  Ureteral  Catheterization. — This  is  the  same  as  that  of 
simple  cystoscopy  up  to  the  point  of  the  introduction  of  the  catheters,  except 
that  it  is  desirable  to  have  the  catheters  in  position  in  the  cystoscope  before 
beginning  the  examination. 

Supposing  the  cystoscope  used  to  be  of  the  indirect  vision  type,  after  the 
bladder  has  been  thoroughly  inspected  and  the  orifices  have  been  located,  one 
of  them  is  focused  in  the  centre  or  to  the  far  side  of  the  centre  of  the  visual  field 
with  the  cystoscope  so  placed  that  the  visual  rays  are  as  nearly  as  possible  per- 
pendicular to  the  bladder  wall  at  this  point.  The  catheter  in  the  side  of  the 
instrument  corresponding  to  the  ureter  to  be  catheterized  is  then  advanced  till 
its  tip  impinges  on  the  far  side  of  the  field,  bisecting  the  field  and  passing 
directly  across  the  ureteral  opening.    If  the  catheter  tends  to  pass  to  one  side 


CYSTOSCOPY  53 

of  the  middle  it  is  because  it  is  bent;  it  should  then  be  twisted  between  the 
fingers  till  it  assumes  a  median  position.  The  deflector  is  then  raised  till  the 
tip  of  the  catheter  appears  to  be  directly  over  the  mouth  of  the  ureter,  when  it  is 
again  pushed  forward,  the  deflector  being  either  raised  or  lowered  sufficiently  to 
secure  entrance  into  the  duct.  The  deflector  is  then  lowered,  the  cystoscope 
turned  to  the  other  ureter,  and  the  second  catheter  inserted  in  a  similar  manner. 

In  direct-vision  cystoscopes  the  catheter  is  merely  advanced  toward  the 
orifice,  the  ocular  of  the  cystoscope  being  moved  up  or  down  or  from  side  to  side 
till  the  catheter  has  engaged. 

For  the  collection  of  urine  the  catheter  is  inserted  to  a  depth  of  ten  or 
fifteen  centimetres,  being  constantly  observed  the  while  through  the  cysioscope 
to  note  at  once  the  occurrence  of  buckling;  if  it  is  desired  to  explore  the  ureter 
or  medicate  the  renal  pelvis  the  catheter  is  advanced  till  an  obstruction  is 
encountered, , a  distance  of  from  28  to  35  cm.  In  the  former  position  the  drip 
from  the  catheter  consists  of  a  series  of  drops  and  then  a  pause;  in  the  latter 
the  drops  follow  one  another  at  equal  intervals.  In  collecting  urine  the  first 
cubic  centimetre  coming  from  the  catheter  after  it  has  entered  the  ureter 
should  be  discarded  to  avoid  contamination  with  fluid  from  the  bladder. 

Failure  of  the  urine  to  flow  through  the  catheters  after  their  introduction 
into  the  ureters  may  be  due  to  plugging  of  the  catheters  or  to  reflex  anuria. 
The  catheters  having  been  patent  at  the  time  of  their  introduction,  the  former 
is  the  result  of  the  eye  of  the  catheter  lying  against  a  fold  of  mucous  membrane, 
or  being  plugged  with  blood  or  pus.  To  secure  a  flow  the  catheter  should  be 
rotated,  advanced  slightly  or  withdrawn  a  short  distance,  or  a  drachm  or  two 
of  sterfle  water  may  be  injected  to  free  the  lumen.  Reflex  anuria,  due  to  the 
presence  of  the  catheter,  or  even  of  a  cystoscope  alone,  may  be  either  partial  or 
complete,  and  may  last  for  half  an  hour  or  even  longer.  The  condition  must 
be  kept  in  mind  in  making  a  diagnosis  of  renal  inactivity  when  an  instrument 
has  been  in  the  bladder  during  the  examination. 

The  collection  of  urine  may  be  done  either  with  the  cystoscope  still  in  position, 
or  this  instrument  may  be  withdrawn,  the  catheters  being  left  undisturbed.  This 
is  done  with  the  Brown-Buerger  type  of  instrument  by  removing  the  rubber 
caps  (cutting  off  the  expanded  ends  of  the  catheters,  one  obliquely  and  the  other 
straight  across,  to  aid  in  subsequent  identification),  turning  the  cystoscope  so 
that  the  beak  points  up  if  it  be  not  already  in  that  position,  lowering  the  deflector, 
and  then  withdrawing  first  the  optical  system  and  then  the  sheath,  being  careful 
that  the  catheters  do  not  catch  on  the  instruments  at  any  point.  The  ends  of  the 
catheters  are  then  placed  in  test-tubes  or  bottles  till  the  desired  quantity  of 
urine  has  accumulated.  The  greatest  care  must  be  exercised  to  avoid  confusing 
the  urine  from  the  two  sides. 

The  catheters  should  be  removed  by  very  gentle  traction,  to  avoid  traumatism 
to  the  ureters. 

RONTGENOLOGY 

Radiography  has  a  number  of  important  uses  in  conjunction  with  cystoscopy, 
ureteral  catheterization,  and  the  injection  of  such  silver  preparations  as  collargol 
(10  to  15  per  cent.),  emulsion  of  the  iodide  in  mucilage  of  quince  seed  (5  to  10 


54  GEXITO-URIXARY  SURGERY 

per  cent.),  and  argjTol  (25  per  cent.),  or  thorium  (10  to  15  per  cent.),  by 
enabling  one  to  determine  the  outlines  and  positions  of  ureters  and  kidney  pelves. 
B}'  its  aid  we  are  able  to  recognize  and  differentiate  the  various  grades  of  dilatation 
of  the  pelvis,  hydronephrosis,  and  hydro-ureter,  and  in  many  cases  to  recognize 
the  obstructive  cause  of  the  condition,  to  differentiate  between  stones  in  the 
ureter  and  phleboliths  and  calcified  h^mph-nodes  in  its  course,  to  trace  the 
course  of  aberrant  ureters,  to  recognize  anomalies  of  the  kidneys,  both  of  struc- 
ture and  position,  and  in  some  cases  to  differentiate  between  tumors  of  the 
kidne3'S  and  other  abdominal  organs. 

The  position  of  the  ureters  may  be  determined  by  passing  catheters  containing 
flexible  ^ire  stylets,  or  those  impregnated  with  a  metal  or  metallic  salt  which  is 
obstructive  to  the  X-rays.  If  the  outline  of  the  ureters  or  pelves  is  desired,  how- 
ever, it  is  necessarj^  to  inject  them  vnth  one  of  the  solutions  mentioned  before 
making  the  skiagram.  For  this  purpose  a  catheter  is  introduced  to  the  kidney 
pehis  and  all  the  contained  urine  drained  off.  Either  of  two  techniques  may 
then  be  followed.  The  first  is  to  determine  the  size  of  the  kidney  pelvis 
and  ureter  by  slowly  injecting  a  colored  solution,  as  indigocarmin  or  methy- 
lene blue,  watching  for  the  appearance  of  the  dye  beside  the  catheter  at  the 
ureteral  orifice,  and  stopping  the  injecting  at  this  point  or  when  the  patient 
complains  of  discomfort.  The  fluid  is  then  allowed  to  drain  off,  a  slightly 
smaller  quantit}'  of  the  silver  preparation  is  injected,  and  the  skiagram  made 
immediately.  The  second  plan  is  to  inject  only  the  silver  solution,  stopping 
the  injection  when  the  patient  complains  of  the  least  pain,  and  noting  the 
amount  injected  as  the  pehic  capacit^^  The  solutions  should  be  injected  by 
gravit}'  from  a  burette  at  an  elevation  of  not  more  than  one  foot.  A  pelvic 
capacity  of  20  c.c.  is  within  the  normal  limit.  The  catheter  should  be  with- 
drawn 10  cm.  before  making  the  injection. 

The  first  skiagram  should  be  made  of  the  kidney  and  upper  ureter.  If  disease 
or  obstruction  in  the  ureter  is  suspected,  a  plate  should  then  be  made  of  the 
lower  portion  of  the  ureter,  the  catheter  being  partially  -ndthdrawn  and  a  little 
additional  solution  injected  to  assure  a  good  shadow  in  this  portion  of  the  tract. 
If  ptosis  of  the  kidnej-  is  suspected,  a  third  plate  should  be  made  with  the 
patient  in  the  erect  posture. 

THERAPEUTIC  APPLICATIONS  OF  THE  CYSTOSCOPE 

Lavage  of  the  Renal  Pelves. — Many  cases  of  pyeUtis  are  benefited  by 
the  direct  application  of  lotions  to  the  pelvic  mucosa.  For  this  purpose  a  cathe- 
ter is  passed  through  the  ureter  till  its  eye  lies  within  the  renal  pelvis,  as 
indicated  by  the  regular  drop  of  urine.  The  solution  of  choice  (any  one  suitable 
for  irrigation  of  the  bladder  may  be  used)  is  then  injected  through  the  catheter 
into  the  pelvis,  the  exact  manner  of  the  injection  depending  on  the  nature  of 
the  catheter  emplo\'ed.  If  a  Xo.  5  F.  has  been  used,  the  lotion  may  be  injected 
slowty  in  large  quantities  by  graxdty  (one  foot  elevation),  the  space  beside  the 
catheter  being  depended  upon  for  the  escape  of  the  fluid.  If  a  larger  catheter 
has  been  used,  the  lotion  should  be  injected  in  quantities  of  10  to  15  c.c,  one 
portion  being  allowed  to  drain  off  through  the  catheter  before  the  next  is  intro- 
duced. Two-way  catheters  are  made  specially  for  use  in  pelvic  lavage,  but  the 
passages  are  necessarily  so  small  that  the  catheters  are  of  little  value. 


CYSTOSCOPY 


55 


Kidney  Drainage.— Pathological  conditions  of  the  kidney  dependent  for 
their  origin  and  perpetuation  on  urinary  back  pressure  from  obstructions  in  the 
ureter  {e.g.,  kinks)  are  greatly  benefited  by  inserting  a  catheter  to  the  pelvis 
and  allowing  it  to  remain  in  this  position  for  some  time,  up  to  six  or  eight  hours. 


Fig.   31. — Cystoscopic  forceps. 


Fig.  32. — Young's  cystoscopic  rongeur. 


Dilatation  of  the  Ureter. — This  is  used  for  the  correction  of  strictured 
conditions,  and  also  in  the  normal  ureter  to  favor  the  passage  of  ureteral  calculi. 
The  stretching  may  be  performed  by  the  passage  of  progressively  larger  catheters 
of  the  olivary  tipped  variety,  or,  better,  by  the  use  of  conical  ureteral  bougies 


56 


GENITO-URINARY  SURGERY 


for  the  smaller  strictures,  and  the  conical  Garceau  catheter  (Fig.  30),  increasing 
in  size  from  6  F.  at  its  tip  up  to  11  F.,  for  the  wider  dilatations  in  the  lower 
portion  of  the  ureter.  Further  enlargement  may  be  secured  if  necessary  by 
incising  the  uretheral  orifice  with  scissors  or  knife  through  an  operating  cysto- 
scope  for  as  much  as  half  an  inch,  or  by  treating  it  with  the  high-frequency 
current  for  a  few  seconds  by  means  of  an  electrode  inserted  in  the  orifice. 

As  a  further  aid  to  the  passage  of  a  stone  several  cubic  centimetres  of  olive 
oil  may  be  injected  in  its  vicinity  by  means  of  a  catheter. 

Removal  of  Small  Calculi  and  of  Foreign  Bodies. — This  may  be  done 
by  grasping  forceps  (Fig.  31)  manipulated  through  an  operating  cystoscope, 
or  by  means  of  Young's  cystoscopic  rongeur  (see  Fig.  32).    The  size  of  the  body 


Fig.  33. — High-frequency  treatment  with  large  type  of  coil  machine.  M,  high-frequency 
machine,  attached  to  street  current  at  C,  and  delivering  Gudin  current  to  patient.  B,  battery. 
.b,   foot   switch. 

that  m.ay  be  so  removed  varies  with  the  calibre  of  the  urethra  and  the  com- 
pressibility of  the  object.  Calculi  lodged  in  the  ureteral  orifices  can  sometimes 
be  dislodged  by  traction  with  cystoscopic  forceps. 

Electro-coagulation ;  "  Desiccation  "  or  "  Fulguration  "  with  the  High- 
frequency  Current. — The  destruction  of  certain  bladder  tumors,  especially  the 
papillomata,  by  means  of  the  Oudin  and  D'Arsonval  high-frequency  currents  is 
now  recognized  as  the  best  method  of  treatment  of  these  neoplasms.  The  patient 
is  not  confined  as  a  result  of  the  treatment,  a  general  anaesthetic  is  not  required, 
the  destruction  of  the  tumor  is  assured,  and  the  percentage  of  permanent  cures  is 
greater  than  that  attained  by  excision,  whether  performed  by  the  transurethral 
(with  operating  cystoscope)  or  suprapubic  routes;  in  case  of  recurrence  the 
patient  does  not  seriously  object  to  repetition  of  treatment. 


CYSTOSCOPY  57 

The  currents  may  be  derived  from  either  a  plate  or  a  coil  machine;  there 
seems  to  be  no  difference  in  the  therapeutic  effect.  The  Oudin  current  is  the  one 
most  frequently  used  (Fig.  33). 

While  the  papillomata  present  the  most  favorable  field  for  the  use  of  the 
currents,  small  median  lobe  enlargements  of  the  prostate  have  been  attacked 
with  success,  and  it  has  been  found  possible  to  fracture  some  calculi  by  their 
application.    They  are  not  effective  against  carcinoma. 

The  currents  are  applied  by  means  of  specially  insulated  wires  introduced 
through  the  catheter  channels  of  a  catheterizing  cystoscope.  The  ware  should 
project  not  more  than  one-sixteenth  of  an  inch  beyond  the  insulation. 

Application  is  made  by  pressing  the  wires  into  the  tumor  for  a  distance  of 
two  or  three  millimetres,  allowing  the  current  to  flow  for  ten  to  forty-five  seconds 
with  a  spark  gap  of  Y12  to  %  inch.  The  effect  on  the  tumor  is  a  species  of 
desiccation  or  oxidation,  the  portion  treated  sloughing  off  in  the  course  of  a  few 
days.  From  four  to  twelve  applications  may  be  made  at  one  seance.  The  treat- 
ments should  be  administered  at  intervals  of  one  to  three  weeks,  the  number 
required  varying  with  the  size  of  the  tumor  and  the  number  of  applications 
made  at  each  sitting.  Hemorrhage  is  usually  checked  by  the  treatment,  but  in 
some  cases  the  bleeding  is  increased,  even  to  an  alarming  degree. 

Topical  Applications. — The  application  of  medicaments  directly  to  bladder 
lesions,  their  curettement,  or  cauterization  are  rarely  indicated.  Occasionally, 
however,  tuberculous  ulcers  and  granulomata  and  indolent  nontuberculous 
conditions  are  benefited  by  such  treatment.  They  are  best  carried  out  with  the 
bladder  distended  with  air,  the  patient  being  placed  in  the  Trendelenburg  position 
and  the  treatment  conducted  through  a  cystoscope  having  a  simple  straight  tube, 
such  as  that  of  Braasch. 


CHAPTER  VI 

SUPPRESSION,  RETENTION,  AND  INCONTINENCE 

OF  URINE 

SUPPRESSION  OF  URINE 

By  suppression  of  urine  is  meant  the  failure  of  the  kidneys  to  perform  their 
excretory  function.  It  must  be  distinguished  from  retention  of  urine  in  the  lower 
urinary  tract.    Such  retention  may  occasion  suppression. 

The  causes  of  suppression  are  ( 1 )  nonobstructive  and  ( 2 )  obstructive. 

Nonobstructive  suppression  develops  in  crippled  kidneys  secondary  to 
trauma — even  trifling  trauma — especially  that  of  the  genito-urinary  tract.  It 
may  follow  severe  systemic  injury  and  is  an  occasional  postanaesthetic  and  post- 
operative complication.  It  is  partly  reflex,  partly  toxic,  as  in  the  case  of  extensive 
burns  of  the  skin,  and  may  be  brought  about  by  the  passive  congestion  incident 
to  extreme  cardiac  weakness. 

The  symptoms  of  nonobstructive  suppression,  aside  from  the  failure  to  pass 
water  or  to  present  the  evidences  of  fluid  retained  in  the  bladder  or  renal  pelves, 
are  those  of  uraemia. 

Obstructive  suppression  is  that  associated  with  blocking  of  the  ureters  or 
of  the  vesical  outlet. 

The  symptoms  of  obstructive  anuria  may  be  veiled  by  an  accompanying 
retention,  but  failure  of  further  excretion  on  relieving  the  retention,  and  the 
later  development  of  uraemic  symptoms  will  sufficiently  mark  the  diagnosis. 

Treatment. — After  operations  on  the  genito-urinary  organs,  free  diuresis 
should  be  secured,  and  for  this  purpose  the  free  ingestion  of  water  and  enteroclysis 
of  half-normal  salt  solution  are  beneficial.  In  all  cases  of  failure  of  the  urinary 
secretion,  active  elimination  should  be  secured  by  hot  packs,  vapor  baths,  in 
some  cases  by  pilocarpin  hypodermically,  and  by  free  purgation  by  calomel  and 
the  saline  cathartics.  In  the  common  form  of  suppression  due  to  reflex  sympa- 
thetic causes,  hot  poultices,  cupping,  and  other  counter-irritants  are  useful, 
and  it  is  here  that  high  hot  injections  of  salt  solution  into  the  colon  are  doubly 
indicated.  Hypodermic  injections  of  caffein  sodiobenzoate  (in  three  grain  doses) 
sometimes  seem  to  have  a  beneficial  effect  on  the  kidneys.  If  shock  be  the  cause, 
intravenous  injections  of  adrenalin  chloride  or  pituitrin  are  indicated. 

The  various  operative  procedures  which  have  been  beneficial  for  suppression 
per  se,  aside  from  those  directed  to  its  cause,  are  passage  of  the  ureteral  catheter, 
with  or  without  pelvic  lavage,  simple  puncture  of  the  kidney,  splitting  the  cap- 
sule, incisions  into  the  capsule,  decapsulation,  and  nephrotomy.  These  opera- 
tions (described  elsewhere)  should  not  be  done  until  other  measures  have  failed, 
nor  should  they  be  postponed  until  the  patient  becomes  apparently  moribund, 
though  even  then  they  have  been  successful.  Operative  measures  are  indicated 
if  three  days  of  conservative  treatment  have  proven  futile,  though  cases  cured 
after  eight  days  are  reported.  A  local  cause,  such  as  a  blocking  calculus,  should 
be  suspected  and  searched  for  in  the  absence  of  an  acute  toxaemia  or  a  preceding 
history  of  chronic  renal  degeneration. 
68 


SUPPRESSION  AND  RETENTION  OF  URINE  59 

RETENTION  OF  URINE 

Retention  implies  inability  to  empty  the  bladder.  This  may  be  due  to  atony 
or  paralysis  of  the  detrusor  muscles,  to  reflex  spasmodic  action  of  the  sphincters, 
or  to  obstruction  at  the  neck  of  the  bladder  or  in  the  urethra. 

Locomotor  ataxia,  Pott's  disease,  general  palsies,  sclerosis  and  severe  cerebro- 
spinal injuries  may,  by  interference  with  the  vesical  centre  of  the  cord,  occasion 
paralytic  retention.  The  muscles  may  be  directly  paralyzed  by  over-distention, 
by  inflammation  extending  from  the  mucous  coat  or  from  the  peritoneal  invest- 
ment, as  in  peritonitis,  or  as  the  result  of  degeneration  consequent  upon  pro- 
longed exhausting  diseases. 

Spasmodic  retention  may  follow  shock  or  injury,  operations  upon  the  sper- 
matic cord,  the  rectum,  or  the  testicles,  or  prolonged  voluntary  retention. 
Obstruction  at  the  vesical  orifice  may  be  due  to  tumor,  impacted  stone,  clot, 
foreign  body,  or  prostatic  hypertrophy. 

Retention  may  be  of  sudden  or  of  gradual  onset,  and  may  be  partial  or 
complete. 

The  retention  of  sudden  onset  is  typified  by  that  observed  in  cases  of  rupture 
of  the  urethra,  or  of  impacted  stone,  or  of  reflex  spasm  following  operations  on 
the  anus.  The  symptoms  are  pains  felt  in  the  region  of  the  bladder  and  steadily 
increasing  in  intensity,  recurrent  unavailing  efforts  at  micturition  with  a  constant 
torturing  desire,  extreme  tenderness  over  the  region  of  the  bladder,  and  the 
formation  of  a  distinct  tumor,  dull  on  percussion,  globular  in  shape,  and  some- 
times extending  as  high  as  the  umbilicus.  Rectal  and  suprapubic  palpation 
show  that  this  tumor  is  fluctuating,  and  that  it  occupies  the  position  of  the 
distended  bladder.    The  final  proof  is  afforded  by  catheterization. 

Gradual  retention  may  develop  so  insidiously  that  it  is  not  suspected  until 
direct  examination  shows  the  presence  of  bladder-distention.  Urethral  stricture,  . 
lesions  of  the  cord,  intracystic  and  extracystic  growths  or  inflammations,  enlarge- 
ment of  the  prostate,  and  atrophy  of  the  detrusor  muscles  are  common  causes 
of  this  form  of  retention.  The  early  symptom  is  frequent  micturition,  the  stream 
passing  with  little  force  and  often  with  much  diminished  volume.  This  frequency 
is  due  to  the  fact  that  the  bladder  is  unable  to  empty  itself  entirely,  a  certain 
amount  of  residual  urine  remaining. 

Even  when  the  vesical  muscles  are  healthy,  if  the  flow  of  urine  is  so  obstructed 
that  the  time  required  to  empty  the  bladder  is  unduly  prolonged,  the  involuntary 
detrusor  muscles,  becoming  tired,  relax  before  the  bladder  is  thoroughly  empty, 
thus  allowing  a  certain  amount  of  residual  urine.  This  residual  urine  is  propor- 
tionate in  quantity  to  the  degree  of  obstruction  encountered  in  the  urethra  and 
to  the  loss  of  tone  of  the  bladder  muscles.  When  sterile  and  moderate  in  amount 
the  only  symptom  it  causes  is  increased  frequency  of  urination.  The  reason 
for  this  is  obvious:  if  the  bladder  cannot  hold  more  than  ten  ounces  comfortably, 
and  if,  when  it  is  full,  an  unsuccessful  effort  is  made  to  empty  it,  five  ounces 
remaining,  the  desire  to  urinate  will  again  occur  when  five  more  ounces  have 
been  secreted  by  the  kidneys,  since  the  bladder  will  then  contain  ten  ounces. 
Its  capacity  as  a  receiver  of  urine  from  the  kidneys  is  lessened  proportionately 
to  the  amount  of  residual  urine  it  contains. 


60 


GEXITO-URIXARY  SURGERY 


When  the  retained  urine  exceeds  four  to  six  ounces,  because  of  the  frequent 
urinations  and  the  more  or  less  sustained  tension,  there  develops  a  certain  degree 
of  chronic  congestion  of  the  bladder,  which  is  often  markedly  increased  by- 
cystitis  and  fermentation  of  the  stagnant  urine. 

As  the  obstruction  gradually  increases,  and  as  the  muscles  become  atonic 
or  atrophic  from  congestion,  iniiammation,  and  overstretching,  the  bladder  is 
more  and  more  dilated,  until,  finally,  it  may  reach  enormous  proportions.  When 
this  gradual  retention  occurs  in  the  course  of  fevers, — typhoid,  for  instance, — 
it  is  probably  due  to  degeneration  of  the  detrusor  muscles  and  to  aboHtion  of 
the  normal  reflex.  The  bladder  may  then  slowly  distend,  giving  rise  to  no 
S3'mptoms  other  than  apparent  incontinence,  the  sphincter  muscle  yielding  when 
the  intravesical  tension  becomes  sufficiently  high  and  allowing  the  urine  to  trickle 


5  4. — Tumor    forrr.ed 


trophied  prostate. 


Gradual    distention    from    hyper- 


slowly  away.  The  same  gradual  unsuspected  distention  develops  in  chronic 
prostatic  overgrowth,  the  symptoms  suggesting  incontinence  rather  than  re- 
tention, and  the  true  condition  not  being  suspected  till  inspection  or  palpation 
shows  a  hypogastric  tumor  (see  Fig.  34). 

When  associated  \\ath  fevers,  and,  indeed,  under  all  circumstances,  incon- 
tinence of  urine  should  lead  to  careful  examination  for  an  over-distended  bladder. 

When  the  bladder  is  able  to  empty  itself  partially,  the  retention  is  incom- 
plete. When  no  urine  can  be  passed,  it  is  complete.  In  either  case  there  results 
an  abnormal  intravesical  tension,  intermittent  when  the  function  of  micturition 
is  not  entirely  suppressed,  continuous  and  steadily  increasing  in  case  of  complete 
retention. 

The  Effects  of  Retention. — Guyon  and  Albarran  have  shown  experi- 
mentally that  even  a  moderate  amount  of  retention  causes  distinct  vesical  con- 
gestion, followed,  if  the  retention  is  not  relieved,  by  ecchymoses,  bloody  extra- 


SUPPRESSION  AND  RETENTION  OF  URINE  61 

vasation,  involving  the  whole  thickness  of  the  bladder-walls,  and  pronounced 
epithelial  desquamation.  The  ureters  and  the  kidney  pelves  and  tubules  show 
the  same  changes, — i.e.,  intense  congestion  and  parenchymatous  ecchymoses  and 
epithelial  degeneration  and  shedding.  The  peritoneum  overlying  the  bladder  is 
often  congested  and  ecchymotic,  and  the  intestines  and  abdominal  viscera  par- 
ticipate in  the  general  vascular  engorgement. 

As  a  result  of  over-distention  the  detrusor  muscles  of  the  bladder  are  para- 
lyzed, remaining  absolutely  flaccid,  even  though  the  urine  be  drawn.  The 
desquamation  of  the  stratified  pavement  epithelium,  which  when  normal  and 
unbroken  prevents  absorption  from  the  bladder,  exposes  the  lymph-  and  blood- 
channels,  thus  favoring  systemic  infection  and  toxaemia.  Ultimately  the  sphincter 
muscle  and  valve  at  the  vesical  orifice  of  the  ureter  becomes  insufficient,  since 
even  inert  bodies,  such  as  powdered  charcoal,  will,  if  injected  into  the  bladder, 
ascend  in  small  quantities  into  the  kidney  pelves. 

Death  results  from  uraemia,  very  exceptionally  from  rupture.  The  tempera- 
ture in  the  absence  of  infection  is  normal  or  sub-normal.  The  extent  and  severity 
of  the  lesions  described  are  dependent  on  the  degree  of  vesical  distention,  and 
this  in  turn  is  proportionate  to  the  duration  of  the  complete  retention  and  the 
quantity  of  urine  secreted. 

As  a  result  of  experimental  research  and  clinical  study,  the  immediate  effects 
of  extreme  acute  distention  of  the  bladder  may  be  summarized  as  follows:  The 
bladder,  prostate,  ureters,  and  kidneys  are  enormously  congested.  The  muscles 
of  the  bladder  become  insufficient,  and  their  fasciculi  are  often  mechanically 
separated  by  the  distention,  producing  the  ribbed  or  trabeculated  bladder.  The 
kidneys,  at  first  excited  to  increased  activity,  as  pressure  increases  secrete 
slowly  or  not  at  all.  Exceptionally,  after  relief  of  tension,  anuria  develops; 
more  frequently  there  is  pronounced  polyuria.  The  whole  urinary  tract  is  ripe 
for  infection,  and  absorption  from  this  tract  takes  place  readily. 

If  microorganisms  are  introduced  into  the  bladder  they  very  rapidly  produce 
cystitis  and  quickly  reach  the  kidneys.  The  introduction  of  similar  organisms 
into  the  healthy  bladder  is  without  evil  effect,  since  the  flat  epithelium  prevents 
their  entrance  into  the  tissues,  and  the  intermittent  stream  of  water  from  the 
ureters  keep  them  from  ascending  along  these  channels. 

Chronic  retention  produces  pathological  alterations  which  are  less  imme- 
diately threatening  than  those  of  acute  retention.  There  is  chronic  congestion 
of  the  entire  urinary  apparatus,  with  pronounced  susceptibility  to  infection. 
When  the  retention  is  moderate  and  incomplete  these  changes  are  limited  solely 
to  the  bladder,  since  the  ureters  and  kidneys  are  affected  only  when  vesical 
tension  has  been  long  continued  or  of  considerable  degree. 

If  fever  develops,  it  is  nearly  always  due  to  concomitant  infection,  and  not 
to  retention  itself.  The  temperature  is  normal  or  subnormal  in  both  acute  and 
chronic  retention. 

Although  the  immediate  effects  of  chronic  retention,  the  use  of  the  term 
chronic  necessarily  implying  that  the  retention  is  incomplete,  are  less  serious 
than  those  of  acute  retention,  the  ultimate  results  are  equally  disastrous,  the 
bladder  dilating  and  losing  tonicity,  and  the  ureters,  kidney  pelves,  and  kidneys 
becoming  involved. 


62 


GENITO-URINARY  SURGERY 


The  bladder  muscle  may  be  completely  and  permanently  paralyzed,  or, 
where  the  retention  is  partial,  particularly  in  case  of  stricture,  it  may  be  greatly 
hyper trophied.  This  hypertrophy  is  none  the  less  followed  by  dilatation  of  the 
ureters  and  their  pelves  and  profound  alterations  in  the  stricture  of  the  kidneys. 
(Fig.  35.) 

The  general  treatment  of  acute  and  of  chronic  retention  calls  for  relief  of 
tension  as  soon  as  possible,  and  the  observance  of  rigorous  antiseptic  precautions 
in  the  use  of  the  catheter.  Sudden  evacuation  of  the  bladder  in  cases  of  chronic 
retention  often  occasions  bleeding  not  only  from  the  bladder,  but  also  from  the 


Fig.    35. — Hypertrophied   bladder   from   urethral    stricture.      Dilatation 
of  ureters  and  kidney  pelves. 

kidneys  and  into  the  substance  of  these  organs.  This  is  less  liable  to  occur  when 
the  urine  of  acute  retention  is  drawn.  It  is  due  to  the  rapid  diminution  of 
pressure  to  which  engorged  vessels  have  long  become  accustomed.  The  renal 
congestion  is  often  evinced  by  blood-casts. 

Exceptionally,  after  the  first  evacuation  there  may  be  such  marked  relief  of 
congestion  that  the  power  of  micturition  is  restored.  Usually  catheterization 
must  be  employed  for  some  time.  Where  there  is  polyuria — and  this  is  fre- 
quently the  case — it  is  important  to  catheterize  the  bladder  frequently.  This 
manipulation  may  have  to  be  repeated  every  two  hours.    The  intervals  should 


SUPPRESSION  AND  RETENTION  OF  URINE  63 

be  such  that  not  more  than  eight  to  twelve  ounces  shall  accumulate  before  being 
drawn. 

From  an  etiological  standpoint  retention  of  urine  may  be  classified  as  follows: 

1.  Retention  due  to  paresis  or  incoordination  of  the  bladder  muscles. 

2.  Retention  from  congestion  or  acute  inflammation. 

3.  Retention  due  to  blocking  of  the  urethra  by  clots,  foreign  body,  stone,, 

or  portions  of  new-growth. 

4.  Retention  caused  by  prostatic  enlargement. 

5.  Retention  caused  by  stricture. 

6.  Retention  due  to  traumatism. 

Retention  of  Urine  Due  to  Incoordination  of  the  Bladder  Muscles 

Under  this  heading  are  classed  those  cases  in  which  narrowing  or  pathological 
alteration  of  the  channel  of  exit  for  the  urine  plays  no  part.  The  cause  of 
retention  is  either  failure  of  detrusor  power  or  loss  of  control  over  the  sphincters, 
these  not  relaxing  as  they  normally  should  when  the  detrusors  contract.  This 
form  of  retention  is  common  in  cerebral  injury,  in  hemiplegia,  in  paraplegia,  in 
spinal  injury  or  disease,  in  Pott's  disease,  and  in  spinal  ataxias.  In  ataxic  cases 
the  retention  may  be  from  sensory  failure,  the  patient  not  perceiving  when  the 
bladder  is  full;  a  catheter  must  then  be  used  not  according  to  a  feeling  of 
vesical  repletion,  but  at  certain  definite  times. 

The  retention  sometimes  observed  in  shock,  hysteria,  peritonitis,  paravesical 
inflammation,-  exhausting  diseases,  neurasthenia,  and  voluntary  postponement 
of  the  act  of  micturition  may  be  partly  spasmodic,  but  is  probably  due  in  the 
main  to  muscular  atony  and  disordered  reflex  action.  Retention  following 
operations  about  the  anus  or  complicating  a  full  rectum  is  usually  spasmodic,, 
the  sphincter  being  excited  to  undue  irritability  not  only  by  the  nervous  reflex^ 
but  also  by  the  vascular  engorgement  consequent  on  these  operations. 

Symptoms. — Retention,  whatever  be  its  cause,  is  characterized  by  the  same 
symptom,  i.e.,  the  formation  of  a  fluctuating  tumor  in  the  bladder  region.  In 
cases  of  paraplegia  or  abolition  of  sensibility  the  pain  and  frequent  efforts  at 
urination  are  wanting.  Under  other  circumstances,  if  the  retention  has  been  of 
sudden  onset,  the  distress  it  occasions  is  characteristic  and  unmistakable.  Since 
the  urethra  is  patulous,  there  develops,  usually  before  there  is  much  back  pressure 
exerted  in  the  direction  of  the  kidneys,  a  dribbling  of  urine,  the  incontinence  of 
retention,  which  is  misleading.  A  patient  who  complains  of  incontinence  should 
always  be  examined  for  retention. 

Diagnosis. — The  probable  absence  of  urethral  or  prostatic  obstruction  will 
be  founded  on  the  patient's  previous  history,  or,  if  this  is  unobtainable,  urethral 
exploration  will  show  that  the  way  to  the  bladder  is  unobstructed.  Spasm  of 
the  compressor  urethrse  may  be  misleading,  but  this  yields  completely  to  the 
gentle,  steady  pressure  of  a  steel  sound  or  catheter. 

When  retention  develops  without  apparent  cause  in  a  person  who  gives  no 
previous  history  of  urethral  or  bladder  trouble,  the  neuropathies  must  be  sus- 
pected, and  search  should  be  made  for  corroborative  signs  of  ataxia. 

Treatment. — Retention  which  is  -a  local  expression  of  hysteria  or  neuras- 


64  GENITO-URIXARY  SURGERY 

thenia  is  usually  relieved  promptly  by  a  hot-water  enema  (103°  F.),  followed 
by  a  hot  sitz-bath  or  general  bath.  The  patient  is  directed  to  pass  the  enema 
while  still  in  the  bath,  and  usually  will  urinate  without  difficulty  during  the  act 
of  defecation.  This  treatment  is  efficient  in  retention  from  constipation,  anal 
operations,  inflammation,  shock,  or  prolonged  voluntary  retention. 

When  the  hot  enema  and  bath  fail,  or  if  these  cannot  be  applied,  catheteriza- 
tion is  indicated.  This  must  be  practised  with  precisely  the  same  care  as  would 
be  exercised  by  the  surgeon  were  he  about  to  perform  a  major  operation,  since 
the  bladder  is  peculiarly  vulnerable  to  sepsis  and  the  kidneys  are  ripe  for  an 
ascending  infection. 

The  evacuating  instrument,  preferably  a  soft  rubber  catheter,  about  No.  16  F., 
is  lubricated,  introduced  as  far  as  the  membranous  urethra,  and  attached  to  an 
irrigating-bag  containing  a  hot  dilute  antiseptic  solution  (2  per  cent,  boric  acid; 
1  to  2000  protargol;  1  to  5000  silver  nitrate,  or  1  to  20,000  bichloride).  A  half- 
pint  of  this  solution  is  allowed  to  flow  through  the  catheter,  thoroughly  irrigating 
the  anterior  urethra;  the  irrigating-bag  is  then  disconnected,  and  the  catheter  is 
passed  into  the  bladder. 

WTien  retention  has  been  chronic  and  progressive,  and  particularly  when  there 
is  also  infection,  the  sudden  emptying  of  the  bladder  is  liable  to  be  followed  by 
severe  hemorrhage,  which,  involving  the  kidneys  and  their  pelves,  may  result 
in  partial  or  complete  suppression  of  urine  and  thus  prove  fatal.  (For  precau- 
tions to  be  taken,  see  p.  72.) 

When  retention  is  due  to  a  central  nerve  lesion,  as  in  Pott's  disease,  trauma, 
or  ataxia,  or  to  muscular  degeneration,  as  in  typhoid  fever  or  in  arteriosclerosis, 
regular  aseptic  catheterization  must  be  practised  as  frequently  as  is  required  to 
prevent  abnormal  vesical  tension.  If  at  any  time  more  than  twelve  ounces  are 
drawn,  this  indicates  that  the  intervals  between  instrumentation  are  too  long. 
Practised  with  due  attention  to  cleanliness,  these  catheterizations  prevent  cystitis, 
since  they  relieve  the  venous  engorgement,  which  is  the  most  potent  predisposing 
factor  to  infection. 

In  all  these  cases  urinary  antiseptics  should  be  administered  by  the  .mouth, 
and  careful  attention  should  be  given  to  the  diet  and  to  general  hygiene. 

Retention  of  Urine  from  Congestion  or  Acute  Inflammation 

WTien,  as  the  result  of  a  severe  gonorrhoea,  an  irritating  injection,  rough 
sounding,  inflammation  of  Cowper's  gland,  or  a  prostatic  abscess,  retention 
develops,  this  may  be  due  partly  to  blocking  of  the  urethra  by  inflammatory 
swelling,  partly  to  spasm.  In  the  vast  majority  of  cases  neither  spasm  nor  acute 
urethritis  is  competent  to  cause  complete  retention.  When  this  develops  there 
is  usually  a  preexisting  lesion,  such  as  stricture  of  large  calibre,  chronic  prostatitis 
with  sclerosis  and  contracture  of  the  internal  vesical  sphincter,  or  moderate 
prostatic  enlargement,  not  sufficiently  obstructive  in  the  absence  of  acute  in- 
flammation to  cause  even  partial  retention. 

Symptoms. — Aside  from  the  characteristic  symptoms  of  retention,  the  de- 
termination of  the  cause  of  this  condition  will  depend  in  the  main  upon  the 
preceding  history.     If  symptoms  of  enlarged  prostate  or  of  long-standing  gleet 


SUPPRESSION  AND  RETENTION  OF  URINE  65 

are  absent,  and  if  in  the  course  of  an  acute  gonorrhoea,  for  instance,  retention 
develops,  the  cause  of  this  must  be  looked  for  either  in  the  urethra — usually  in 
its  membranous  part — or  in  the  prostate.  Before  exploring  the  urethra  the 
prostate  should  be  palpated  per  rectum;  if  this  is  normal  in  size  and  non- 
sensitive,  urethral  inflammation  and  spasm  may  be  suspected  as  the  cause  of 
retention. 

Treatment. — The  hot  bath  and  hot  enema  are  indicated,  since  instrumenta- 
tion should  be  avoided  because  of  the  danger  of  infecting  the  bladder.  If  these 
measures,  reinforced  by  opium  suppositories  or  morphine  injections,  prove  use- 
less, a  woven  coude  catheter  should  be  passed,  since  the  urethral  spasm  is  so 
tight  that  it  effectively  resists  the  softer  instrument.  This  may  cause  such  agoniz- 
ing pain  that  it  is  well  to  use  a  local  anaesthetic  (eucaine  or  novocaine),  or  even 
to  administer  ether  to  the  first  stage  each  time  it  is  passed.  It  should  be  preceded 
by  urethral  irrigation,  and  should  be  withdrawn  while  an  antiseptic  solution 
is  flowing  through  it. 

When  the  prostate  felt  through  the  rectum  is  large,  hot,  and  tender,  recourse 
may  be  had  to  hot  baths,  enemas,  and  opium,  but  there  is  little  hope  of 
relieving  vesical  tension  by  these  means  unless  the  swelling  is  purely  congestive. 
In  that  case  it  should  subside  promptly  under  treatment,  and  palliative 
measures  should  be  efficient.  Should  they  fail,  the  catheter  must  be  used 
without  delay,  not  only  for  immediate  relief,  but  also  because  by  regularly 
emptying  the  bladder  this  viscus  is  less  likely  to  become  infected.  A  prostatic 
abscess  or  a  suppurative  Cowper's  gland  should  be  opened  as  soon  as  it  is 
detected,  preferably  through  the  perineum. 

Retention  of  Urine  from  Sudden  Blocking  of  the  Urethra  or  the  Vesical  Neck. 

This  form  of  retention  may  be  due  to  the  lodgement  of  a  stone  or  foreign 
body  in  the  urethra,  to  a  pedunculated  bladder-tumor  situated  near  the  neck  of 
the  bladder,  and  acting  as  a  ball-valve,  or  to  blood-clots  sufficiently  firm  to  plug 
the  vesical  orifice. 

Urethral  calculi  and  foreign  bodies  are  considered  in  another  part  of  this 
work. 

Blood-clots  rarely  cause  retention  when  the  urethra  is  unobstructed.  They 
are  liable  to  cause  intermittent  blocking  of  the  urethra,  but  are  ultimately 
expelled.  In  cases  of  prostatic  hypertrophy  or  stricture,  clots  may  cause  absolute 
retention  and  may  seriously  interfere  with  catheterization. 

Symptoms. — Retention  of  urine  from  vesical  clots  will  give  no  character- 
istic symptoms  other  than  those  of  sudden  retention.  Bloody  urine  containing 
small  clots  will  usually  have  been  passed  before  the  retention  develops.  There 
may  be  a  history  of  previous  hemorrhage,  or  of  a  sufficient  cause,  such  as  trau- 
matism, for  extravasation  of  blood.  The  catheter  enters  the  bladder  readily, 
and,  even  though  it  is  almost  immediately  blocked  by  a  clot,  draws  some  bloody 
urine;  suction  by  a  syringe  draws  out  fragments  of  clot  and  allows  the  urine 
to  flow. 

When  the  retention  is  due  to  a  pedunculated  tumor  or  a  small  movable  calcu- 
lus, the  symptoms  may  be  precisely  the  same  as  those  which  characterize  retention 
5 


66         •  GEXITO-URIXARY  SURGERY 

from  clot,  since  there  are  likely  to  be  haematuria  and  sudden  stoppage  of  the 
stream  of  urine.  If,  however,  the  catheter  is  passed  well  within  the  bladder,  its 
eye  is  not  blocked  and  the  urine  fiow^s  freely. 

Diagnosis. — In  deciding  whether  retention  is  due  to  blood-clot,  small,  mov- 
able stone,  or  pedunculated  tumor,  the  history  of  the  case  and  the  course  of 
the  S3Tnptoms  usualty  lead  to  a  correct  opinion.  Thus,  stone  is  preceded  by 
renal  coHc,  by  f requeue}' of  urination,  and  by  pain  felt  just  behind  the  meatus 
at  the  end  of  the  act.  A\Tien  it  is  displaced  from  the  neck  of  the  bladder  by  a 
metal  catheter  a  characteristic  grating  may  be  felt.  The  urine  which  is  drawn 
contains  but  little  blood. 

A  pedunculated  vesical  tumor  may  cause  an  obstruction  which  readily  yields 
to  the  catheter  and  which  bleeds  freely.  The  nature  of  the  obstruction  would 
be  open  to  suspicion  if,  in  the  absence  of  symptoms  of  stone,  the  patient  com- 
plained of  occasional  apparentl}'  causeless  profuse  haematuria;  if  on  the  relief 
of  retention  no  clots  were  dra-^AH,  the  urine  flowing  freely  as  soon  as  the  eye  of 
the  catheter  reached  the  bladder;  and  if  urination  in  the  dorsal  decubitus  pre- 
vented the  stoppage  of  the  stream.  Finalty,  cystoscopic  examination  should 
dennitely  settle  the  matter. 

Treatment. — Retention  from  blood-clot  does  not  necessarily  call  for  imme- 
diate catheterization,  since,  provided  there  is  no  urethral  obstruction,  as  the  clot 
softens  and  disintegrates  it  is  passed  spontaneously;  indeed,  it  is  more  likely 
to  escape  through  the  natural  passage  than  through  a  medium-sized  catheter.  A 
hot  bath  and  an  opium  suppositor}^  or  a  morphine  injection  to  relieve  the 
associated  spasm  of  the  sphincters,  and  efforts  at  urination  made  with  the  patient 
in  the  dorsal  decubitus  and  wdth  the  pelvis  elevated,  usually  result  in  relief. 

Should  these  measures  fail,  the  patient  is  placed  on  his  back  with  the  pelvis 
elevated,  and  a  large  woven  catheter  is  passed  till  its  eye  is  just  within  the 
internal  vesical  sphincter.  This  decubitus  favors  gravitation  of  the  clots  to 
the  upper  posterior  portion  of  the  bladder,  where  they  are  less  likely  to  block 
the  catheter  before  the  main  bulk  of  the  urine  has  been  drawn  off. 

\Mien  the  catheter  becomes  obstructed  from  lodgement  of  a  clot  in  its  eye, 
a  drachm  of  dilute  antiseptic  solution  should  be  injected  forcibly.  If  after  several 
repetitions  of  this  manoeuvre  it  is  apparent  that  the  catheter  cannot  be  kept 
clear  long  enough  to  allow  the  urine  to  flow  in  sufficient  quantity  to  relieve 
tension,  an  eight-ounce  hard  rubber  syringe,  with  a  piston  which  fits  accurately, 
should  be  attached  to  the  end  of  the  catheter  and  the  clots  should  be  sucked 
out.  Should  this  method  fail,  a  large  evacuating  litholapaxy-tube  should  be 
passed,  and  through  it  the  blood  should  be  aspirated. 

If  iDecause  of  a  large  prostate  the  evacuating  tube  cannot  be  passed,  either 
perineal  or  suprapubic  cystotomiy  is  indicated  in  accordance  ^Adth  the  cause  of 
the  bleeding.  In  any  event  the  retention  must  be  relieved  and  the  bladder  freed 
of  clots,  since  the  presence  of  blood  in  the  urine  markedly  favors  the  development 
of  cystitis.  Empt3'ing  the  bladder  is  the  most  efficient  means  of  stopping  further 
bleeding  if  this  is  of  cystic  origin. 

Retention  due  to  a  pedunculated  cystic  tumor  can  be  relieved  by  catheteriza- 
tion, the  instrument  pushing  aside  the  growth  and  preventing  it  from  acting;  as 
a  plug.    The  same  treatment  is  appropriate  to  calculus  lodged  in  the  vesical  neck. 


SUPPRESSION  AND  RETENTION  OF  URINE 


67 


Retention   of    Urine   from    Prostatic   Enlargement 

Of  all  forms  of  urinary  retention,  that  due  to  hypertrophied  prostate  is  the" 
most  frequerit.  This  complication  of  hypertrophy  is  infinitely  more  serious 
than  the  disease  which  causes  it.  It  is  due  to  the  increased  resistance  to  the 
escape  of  urine  offered  by  alterations  of  the  bladder-neck,  elongation  and  deflection 
of  the  prostatic  urethra,  diminution  in  the  calibre  of  the  latter,  and  vesical  atony. 
The  walls  of  the  vesical  orifice  are  thickened,  and  the  opening  is  raised  above 
the  level  of  the  bas-fond,  thus  leaving  a  pouch.    The  overgrowth  may  involve 


Fig.   36. — Hypertrophy  of  the  lateral  and  median  lobes  of  the  prostate.      (Watson.) 

one  or  all  of  the  prostatic  lobes;  usually  the  entire  prostate  is  enlarged.  (Fig.  36.) 
From  overgrowth  of  the  middle  lobe  more  or  less  of  a  projection  is  formed  at 
the  vesical  orifice.  The  enlarged  lateral  lobes  narrow  the  urethra  and  force  it 
to  one  side  or  the  other,  in  accordance  with  the  position  of  greatest  overgrowth. 
(Fig.  37.)  As  a  result  of  this  obstruction  the  bladder  muscles  become  weakened, 
at  least  so  far  as  their  propulsive  power  is  concerned.  There  is  always  very 
marked  hypertrophy  of  individual  fibres  or  fasciculi,  forming  prominent  ridges. 
The  general  symmetrical  hypertrophy  so  frequently  observed  in  partial  retention 


68 


GENITO-URINARY  SURGERY 


following  stricture  is  rarely  found  when  obstruction  is  due  to  prostatic  hypertro- 
phy. Vesical  inertia  is  also  encouraged  by  the  muscular  degeneration  incident 
to  atheroma,  which  so  often  complicates  enlarged  prostate,  cystitis,  prolonged 
venous  congestion,  and  over-distention. 


J  J" 


Fig.  37. — Hypertrophy  of  the  lateral  lobes  of  the  prostate.     (Watson.) 

As  a  result  of  overgrowth  the  prostatic  urethra  may  be  double  or  even  triple 
its  normal  length.  The  vesical  orifice  and  prostatic  urethra  are  encroached 
upon  at  the  expense  of  the  lower  and  lateral  walls.    The  superior  wall  preserves 


SUPPRESSION  AND  RETENTION  OF  URINE  69 

its  normal  direction.    This  fact  is  important  as  bearing  upon  the  proper  use  of 
catheters  for  the  rehef  of  retention. 

The  prostate  may  be  tough  and  fibrous,  presenting  an  obstacle  which  will 
yield  only  to  rigid  instruments,  or  may  be  so  friable  that  it  is  bruised  and 
lacerated  by  even  soft  rubber  catheters  or  exploring  bougies.  Its  dimensions  as 
felt  by  the  rectum  do  not  necessarily  indicate  the  degree  of  urethral  obstruction 
it  occasions. 

Symptoms, — During  the  earliest  stages  of  prostatic  enlargement  no  symp- 
toms are  excited  upon  the  part  of  the  bladder;  as  the  growth  increases,  elevating 
the  internal  vesical  orifice,  there  is  partial  retention,  a  certain  amount  of  residual 
urine  remaining  after  each  micturition.  This,  if  it  is  sterile  and  does  not  exceed 
four  to  six  ounces,  causes  no  symptoms  other  than  a  slight  increase  in  frequency 
of  urination  and  a  habit  of  rising  once  in  the  early  morning  hours  to  empty  the 
bladder. 

As  the  obstruction  becomes  more  pronounced,  residual  urine  increases  in 
amount,  the  desire  to  urinate  comes  more  frequently  and  is  more  imperative, 
especially  at  night ;  there  is  usually  slowness  in  starting  the  stream,  and  this  is 
projected  with  less  force.  Finally,  there  is  distinct  vesical  atony,  the  walls  of 
the  bladder  yield  to  the  slowly  increasing  tension,  and  that  viscus  becomes 
greatly  dilated,  sometimes  extending  above  the  umbilicus.  This  dilatation  involves 
the  ureter  and  the  kidney  pelves.  The  secreting  portion  of  the  kidney  becomes 
insufficient,  a  condition  of  uraemia  develops,  characterized  by  gastro-intestinal 
disorders  and  steady  deterioration  in  health,  and  death  ensues.  When  the 
bladder  reaches  an  extreme  degree  of  distention  there  is  a  constant  dribbling  of 
urine.  It  should  be  noted  that  this  train  of  pathological  changes  may  be  evolved 
without  the  patient  having  the  faintest  conception  that  there  is  a  condition  of 
vesical  tension,  the  symptoms  of  which  he  complains  being  simply  frequent 
micturition,  especially  aggravated  at  night,  often  attributed  to  polyuria,  and 
ultimately  followed  by  incontinence  of  urine,  difficulty  in  starting  the  stream 
and  loss  in  its  force,  and  apparently  causeless  digestive  troubles.  Should  cystitis 
intervene,  the  vesical  symptoms  become  so  marked  that  they  will  scarcely  be 
overlooked.  There  are  then  pain,  tenesmus,  and  all  the  phenomena  of  bladder- 
inflammation  aggravated  by  the  retention. 

If,  in  the  course  of  chronic  incomplete  retention,  the  enlarged  prostate  be- 
comes suddenly  congested  from  infection,  exposure,  sexual  excesses,  indiscre- 
tion in  diet,  or  other  cause,  there  will  result  acute  retention,  characterized  by 
pain  in  the  bladder  and  futile  efforts  at  micturition.  This  acute  retention 
is  often  not  complete,  the  patient  being  able  to  pass  a  portion  of  his  water, 
but  only  after  violent  straining. 

Diagnosis. — Retention  due  to  prostatic  enlargement  is  observed  in  men 
past  middle  age.  There  is  a  history  of  frequent  urination,  beginning  with 
night  rising  and  slowly  becoming  more  marked.  Until  an  extreme  degree  of 
tension  is  reached,  this  frequency  is  always  most  marked  in  the  night  or 
early  morning.  Rectal  examination  or  cystoscopy  (see  p.  47)  shows  an  en- 
larged prostate,  and  rectal  and  suprapubic  palpation  demonstrate  a  full  blad- 
der. On  passing  the  catheter  immediately  after  voluntary  micturition,  resi- 
dual urine  is  drawn  and  the  urethra  is  found  to  be  abnormally  long.     To 


70 


GEXITO-URIXARY  SURGERY 


measure  the  urethral  length,  the  catheter  is  introduced  till  the  water  begins 
to  flow;  its  shaft  is  then  pinched  vdth.  the  thumb  at  the  point  corresponding 
to  the  meatus.  The  urethral  length  is  determined  by  withdrawing  the  catheter 
and  measuring  the  distance  from  the  thumb  to  the  eye  of  the  instrument.  Nor- 
mally this  should  be  about  seven  and  a  half  to  eight  inches. 

Retention  from  chronic  prostatitis  accompanied  by  contraction  and  sclerosis 
of  the  internal  vesical  sphincter  gives  the  same  picture,  except  that  the  ure- 
thra is  not  lengthened.  Rectal  palpation  shows  a  small,  hard  prostate,  and 
cystoscopic  examination  fails  to  demonstrate  a  nodular  median  projection  at  the 
vesico-urethral  junction. 

Treatment. — Complete  retention  from  prostatic  enlargement  always  re- 
quires prompt  mechanical  or  surgical  inter\-ention.  The  time  spent  in  pallia- 
tive measures  is  wasted,  and  may  give  an  opportunity  for  the  development 
of  irremediable  lesions.  With  very  few  exceptions,  it  is  possible  to  pass  an 
instrument  into  the  bladder.     The  surgeon  should  be  pro\dded  with  straight 


Fig. 39. — Double-elbowed  catheter. 


Fig.   40: — Silver  prostatic  catheter. 

and  elbowed  soft  rubber  catheters,  each  having  a  large  sunken  eye,  a  solid 
tip,  and  a  funnel  end,  flexible  woven  cylindrical  (Fig.  2),  and  olivary  (Fig.  3), 
woven  catheters,  single  and  double  elbowed  (Figs.  38  and  39),  and  one  or  two  full- 
curved  silver  prostatic  catheters  (Fig.  40),  calibre  16  to  20  F.,  twelve  inches 
in  length,  and  with  an  unusually  long  cun.'e.  The  calibre  of  the  soft  instru- 
ments should  be  from  14  to  18  F.  An  irrigating  apparatus,  provided  \\-ith 
a  conical  glass  nozzle  which  can  be  fitted  into  the  ends  of  the  catheters,  a 
sterile  lubricant,  and  a  sufficient  number  of  sterile  towels,  also  must  be  provided. 
If  the  history  of  a  case  suggests  the  possibility  of  stricture  complicating 
enlarged  prostate,  the  soft,  flexible,  bulbous,  or  olivary  bougies  will  be  required. 
A  preliminary  rectal  examination  having  been  made,  the  urethra  thoroughly 
flushed  out,  and  the  penis  and  glans  cleansed  as  for  an  operation,  a  slit  is 
cut  in  a  sterile  towel,  and  through  this  the  penis  is  slipped;  thus  the  manipu- 
lative area  is  surrounded  by  a  sterile  surface.  The  surgeon,  having  sterilized 
hi.',  hands,  lubricates  a  sterilized  soft  elbowed  catheter  of  medium  size,  passes 
it  to  the  compressor  urethrae  muscle,  attaches  its  free  end  to   the  irrigator, 


SUPPRESSION  AND  RETENTION  OF  URINE 


71 


and  washes  out  the  anterior  urethra.  He  then  anaesthetizes  the  entire  urethra, 
if  this  be  possible,  with  a  five  per  cent,  solution  of  eucaine,  novocaine,  or  alypin, 
applied  by  means  of  the  instillator  (see  p.  26).  Thereafter  he  endeavors  to  pass 
the  elbowed  soft  catheter  into  the  bladder.  When  the  passage  of  the  cathe- 
ter is  not  difficult,  catheterization  may  be  accomplished  without  the 
surgeon's  touching  that  portion  of  the  catheter  which  is  to  be  introduced 
into  the  urethra,  that  part  of  the  instrument  being  handled  by  means  of 
sterile  forceps  (Fig.  41)  or  a  sterile  towel.  When  gently  repeated  efforts, 
continued  for  one  or  two  minutes  at  most,  fail,  the  rubber  catheter  should 
be  attached  to  the  irrigator,  and  should  be  withdrawn  while  a  dilute  anti- 
septic solution  (four  per  cent,  boric  acid)  is  flowing  through  it.  A  woven 
catheter  (coude)   is  then  tried.     The  slight  angle  at  the  end  of  this  instru- 


-^ 


Frc.  41. — Insertion  of  catheter  with  aid  of  forceps. 

ment  is  of  service,  partly  because  it  enables  it  readily  to  override  obstacles,  and 
partly  from  the  fact  that  the  bend  keeps  the  extremity  of  the  instrument  ap- 
plied to  the  upper  urethral  wall.  It  will  be  remembered  that  the  obstruction 
is  found  mainly  in  the  lower  and  lateral  walls  of  the  urethra,  the  upper  portion 
remaining  comparatively  normal.  Hence,  if  the  end  of  the  instrument  is 
kept  constantly  in  close  contact  with  this  normal  surface,  it  can  be  readily 
guided  into  the  bladder.  The  tip  of  the  elbowed  catheter  must,  therefore, 
be  kept  against  the  urethral  roof. 

Should  the  elbowed  catheter  fail  to  gain  an  entrance,  the  double  elbowed 
or  bi-coude  catheter  may  be  tried. 

In  the  event  of  this  failing,  a  soft-rubber  catheter  of  small  calibre,  No.  10 
to  No.  12  F.,  is  slipped  on  one  of  the  iron  wire  stylets  with  which  English 
catheters  are  provided.  The  extremity  of  this  stylet  stops  one  inch  short  of 
the  eye  of  the  catheter.     To  the  soft-rubber  catheter,  thus  made  rigid  biit 


72  ■  GEXITO-URIXARY  SURGERY 

with  a  perfectly  flexible  end,  a  long  curve  is  given  by  bending  the  wire.  This 
corresponds  in  general  with  that  of  the  prostatic  silver  catheter.  This  long 
curve  keeps  the  tip  of  the  instrument  apposed  to  the  urethral  roof  and  thus 
guides  it  into  the  bladder.  The  rigidity  imparted  by  the  stylet  enables  enough 
pressure  to  be  applied  to  overcome  any  resistance  offered  by  the  close  appo- 
sition of  tough  fibrous  walls,  and  the  flexible  end  readily  finds  its  way  over 
or  around  abrupt  projections.  -\11  these  manipiflations  must  be  conducted 
with  the  utmost  gentleness,  3-et  the  most  skilful  manipulation  ■v^■ill  occasion 
bleeding  because  of  the  intense  congestion  which  always  accompanies  retention. 

Should  the  soft  catheter  threaded  on  the  stylet  fail  to  pass,  the  long  pro- 
static silver  catheter  may  be  used.  In  passing  the  catheter  it  must  be  borne 
in  mind  that  the  urethra  is  always  lengthened,  sometimes  two  or  three  inches, 
and  that  the  bladder  ma}-  not  be  reached  because  of  failure  on  the  part  of  the 
surgeon  to  pass  his  instrument  far  enough.  Sometimes  a  long  flexible  whale- 
bone guide  can  be  made  to  pass  the  obstruction,  and  a  tunnelled  catheter  can 
be  passed  over  it,  as  in  cases  of  stricture,  although  this  procedure  is  not  so 
uniforml}-  useful  in  cases  of  prostatic  retention.  Should  gentle  eforts  with 
all  these  instruments,  continued  not  more  than  two  or  three  minutes  for  each,, 
result  in  failure  to  reach  the  bladder,  suprapubic  aspiration  is  indicated  as  a 
measure  of  immediate  reHef. 

Suprapubic  drainage  through  a  cannula  of  large  size  introduced  over  a 
trocar  under  local  ansethesia  (deep  infiltration),  as  a  method  of  continuous 
drainage,  is  attended  -^-ith  more  immediate  risk  than  aspiration,  but  has  given. 
satisfactor}'  results  where  there  was  no  hope  of  relief  by  catheterization. 

In  cases  of  retention  from  prostatic  enlargement  uncomplicated  by  infec- 
tion, and.  particularh"  when  there  have  been  no  pre\ious  futile  attempts  at 
instrumentation,  the  soft-rubber  catheter  or  the  flexible  woven  elbowed  catheter 
usually  enters  the  bladder  without  difficulty.  "\Mien  this  end  is  accomplished 
the  surgeon's  serious  responsibility  practicalh'  begins.  If  as  a  result  of  long- 
standing vesical  tension  there  has  been  dilatation  of  the  ureters  or  of  the  kid- 
ney pelves,  with  marked  alterations  in  the  kidney  structure,  and  particularly 
if  there  has  been  pre\-ious  infection,  or  if  this  is  carried  in  by  instrumentation, 
sudden  evacuation  of  urine  ma}'  be  followed  b}'  suppression,  uraemia,  and  death, 
occiuring  in  either  a  few  days  or  a  few  weeks.  \Mien  the  kidneys  are  com- 
paratively healthy,  sudden  complete  evacuation  of  the  bladder  contents,  by 
interfering  with  the  conditions  of  pressure  to  which  the  blood-vessels  have 
become  accustomed,  may  occasion  severe  hemorrhage  not  only  in  the  bladder 
but  in  the  kidneys  themselves.  This,  even  when  slight  in  degree,  by  favoring 
the  development  of  cystitis,  may  constitute  a  grave  complication.  If  profuse 
it  becomes  serious,  not  only  because  of  its  systemic  effect,  but  also  because 
by  clotting  and  obstructing  the  catheter  it  interferes  \rith  the  flow  of  the  urine. 
To  avoid  bleeding  the  urine  should  be  drawn  off  slowh*.  vdih  the  patient  in 
a  recumbent  position.  Except  when  the  distention  is  slight  and  of  short  dura- 
tion, the  bladder  should  not  be  completely  emptied  at  the  time  of  the  first 
catheterization.  WTien  the  urine  is  clear  and  sterile,  about  half  the  bladder 
contents  should  be  allowed  to  remain.  "When  there  is  blood  or  pus  in  the 
urine,   all   of  this  should  be  drawn   from   the  bladder,   but  v^-ithout   allowing 


SUPPRESSION  AND  RETENTION  OF  URINE  7:^ 

this  viscus  to  be  entirely  empty  at  any  time.  This  end  is  thus  attained:  Before 
passing  the  catheter  the  bladder  is  palpated,  to  enable  the  surgeon  roughly 
to  determine  its  content.  The  catheter  is  introduced  and  somewhat  more  than 
half  the  retained  urine  is  drawn.  This  may  be  two  to  three  pints.  Eight  to 
twelve  ounces  of  a  warm  sterile  four  per  cent,  solution  of  boric  acid  are 
then  injected  into  the  bladder  by  means  of  the  irrigator,  and  immediately  the 
same  quantity  of  mixed  boric  acid  solution  and  urine  is  allowed  to  escape. 
This  partial  filling  and  emptying  of  the  bladder  is  continued  till  the  blood  and 
pus  disappear  and  the  liquid  evacuated  has  the  colorless  appearance  of  the 
boric  acid  solution.  The  catheter  is  then  slowly  withdrawn,  with  the  boric 
acid  solution  still  flowing  through  it. 

The  rule  of  treatment  in  these  cases  should  be  regular  evacuation  of  the 
bladder,  the  number  of  catheterizations  required  daily  being  regulated  by  the 
activity  of  the  kidneys.  Four  to  eight  times  in  twenty-four  hours  are  usually 
sufficient.  Each  time  enough  urine  is  withdrawn  to  lessen  distinctly  the  resid- 
ual amount.  This  residuum  is  then  replaced  by  boric  acid.  In  two  days 
the  bladder  can  usually  be  completely  emptied  without  fear  of  ill  results.  Con- 
tinuance of  catheterization  is  indicated  by  failure  to 
recover  painless,  fairly  effortless,  prompt,  voluntary 
evacuation,  but  not  when  the  passage  of  instruments  is 
difficult,  or  not  longer  than  is  needful  to  prepare  the 
patient  for  an  operation  which  will  radically  cure. 

Continuous  catheterization  is  indicated  when  per- 
sistent vesical  retention  is  complicated  by  a  progres- 
sive asthenia,  gastro-intestinal  breakdown,  and  loss  of 
weight.     The  indications  are  still  more  urgent  when 
Fig    42  — Maiecot     soft  ^ymptoms  of  scpsis  develop,  and  when  microscopic  and 
rubber   self-retaining   cath-  functional  tcsts  Corroborate  the  presence  of  renal  infec- 
tion and  markedly  depressed  function.    The  permanent 
catheter  does  not  lessen  prostatic  enlargement;  it  simply  relieves  congestion  and 
spasm  by  providing  for  free  drainage. 

The  soft-rubber  instruments  are  best  suited  to  permanent  catheterization. 
If  a  woven  catheter  is  employed,  this  should  be  thin-walled,  of  as  large  calibre 
as  possible,  and  provided  with  two  large  terminal  eyes.  They  are  placed  in 
the  turned-up  portion,  and  hence  not  likely  to  be  occluded  by  the  bladder 
walls. 

The  self-retaining  catheter  is  also  useful  (Fig.  42).  This  is  of  soft  rubber^ 
18  to  22  F.,  and  is  provided  with  lateral  terminal  projections,  which  disap- 
pear when  it  is  drawn  tightly  over  the  metal  carrier.  It  is  thus  introduced; 
the  carrier  is  then  withdrawn,  and  the  elasticity  of  the  instrument  causes  the 
projections  to  reappear.  The  surgeon  is  enabled  to  determine  how  far  the 
tip  of  the  instrument  is  passed  into  the  bladder  by  gently  drawing  the  catheter 
out  until  he  feels  the  resistance  caused  by  these  rubber  projections  when  the 
narrowing  of  the  vesical  neck  is  reached.  When  this  resistance  is  felt,  it  is 
certain  that  the  catheter  eye  lies  just  within  the  grasp  of  the  internal  vesical 
sphincter.  If  an  ordinary  catheter  is  used,  the  exact  depth  at  which  it  must 
be  maintained  is  determined  "by  gently  withdrawing  it  when  the  contents  of 


74 


GEXITO-URIXARY  SURGERY 


the  bladder  are  almost  evacuated  and  noting  the  moment  when  the  stream 
ceases  to  flow.  It  is  then  passed  in  again  until  the  stream  begins  to  flow,  and 
is  fixed  at  this  point. 

To  determine  positively  that  the  instrument  is  properly  placed  and  com- 
pletely evacuates  the  bladder,  after  the  stream  has  ceased  to  flow  sudden 
pressure  is  made  in  the  hypogastric  region.  If  the  bladder  is  empty  there 
will  be  no  jet  of  urine.  Next  a  definite  quantity  of  antiseptic  solution  is  in- 
jected into  the  bladder;  all  of  it  should  be  returned  immediately.  Next  the 
end  of  the  catheter  should  be  watched,  to  see  that  the  urine  drops  steadily 
and  continuously. 

\Mien  by  these  tests  the  surgeon  is  assured  that  the  catheter  is  properly 
placed,  it  may  be  secured  in  position.  The  proper  placing  of  the  instrument 
is  the  most  important  part  of  the  whole  procedure. 


Fig.  43. — ^Retained  catheter  (straps  applied). 

The  fixation  of  the  catheter  is  accomplished  by  fastening  threads  to  strips 
of  rubber  adhesive  plaster  an  inch  wide  applied  to  the  sides  of  the  penis, 
passing  from  its  root  to  the  level  of  the  meatus,  and  secured  in  place  by  a 
narrow  gauze  bandage.  The  threads  should  be  attached  to  the  catheter  close 
to  the  meatus  (Figs.  43  and  44j,  and  are  then  passed  through  holes  cut  in 
the  free  ends  of  the  longitudinal  plaster  strips. 

By  means  of  a  piece  of  sterile  glass  tubing  a  clean  rubber  drainage-tube 
is  attached  to  the  end  of  the  catheter  to  drain  the  urine  into  a  urinal  contain- 
ing one  or  two  drachms  of  liquor  formaldehydi  and  placed  at  a  level  lower 
than  that  of  the  bladder.     The  flow  must  be  continuous. 

T^\-ice  daily  the  bladder  is  irrigated  with  a  mild  antiseptic  solution  (boric 
acid,  oi  to  the  pint;  protargol.  1  to  4000).  the  catheter  then  being  slowly 
withdrawn  until  the  washing  solution  passing  through  its  eye  returns  through 
the  meatus.  The  instrument  is  then  reinserted  to  the  proper  depth  and  se- 
cured in   that  position.     A   new  catheter  is  substituted   as  soon   as  the  one 


SUPPRESSION  AND  RETENTION  OF  URINE 


75 


in  use  shows  any  surface  roughness  or  incrustation.  The  time  limit  varies 
greatly,  the  soft-rubber  instruments  lasting  much  longer  than  the  woven  ones. 
The  full  length  of  the  catheter  should  be  inspected  every  second  day. 

Continuous  catheterization  occasions  a  mechanical  urethritis,  which  is  re- 
duced to  minimum  by  the  treatment  indicated  above,  and  which  promptly  dis- 
appears when  the  catheter  is  removed.  Ulceration  of  the  urethral  floor  may 
be  avoided  by  supporting  the  penis  so  that  it  is  prevented  from  hanging  with 
too  pronounced  a  curve. 

Continuous  catheterization  is  usually  employed  by  the  surgeon  as  a  tem- 
porary means  of  relieving  sepsis  and  back  pressure  until  the  patient's  condi- 
tion is  so  improved  incident  to  the  drainage  thus  secured  that  radical  treat- 
ment can  be  adopted.  Even  when  most  skilfully  applied  and  carefully  watched 
it  may  cause  so  much  distress  as  to  become  impracticable.    Perineal  or  supra- 


FlG.  44.— Retained  catheter.     (Dressing  completed  with  bandage.) 

pubic  drainage  is  then  indicated.  Yet ,  in  some  cases  an  indwelling  catheter 
may  be  worn  for  months  or  years,  draining  into  a  urinal  worn  beneath  the  cloth- 
ing, or  being  provided  with  a  clamp,  so  that  the  patient  is  able  to  empty  his 
bladder  intermittently  into  an  ordinary  urinal.  The  long-continued  instru- 
mentation produces  an  ultimate  tolerance  and  fibrosis  characterized  by  the 
almost  complete  absence  of  inflammatory  reaction. 

Aspiration. — When  acute  retention  from  any  cause  is  not  amenable  to 
catheterization,  aspiration  is  the  emergency  treatment  of  choice.  It  can  be 
performed  repeatedly  without  causing  complications. 

The  bladder  is  outlined  by  percussion  and  palpation,  and  the  suprapubic 
region  is  cleansed  as  for  a  surgical  operation.  With  a  sterile,  sharp-pointed 
tenotome  a  puncture  is  made  through  the  skin  of  the  middle  line  immedi- 
ately above  the  symphysis  pubis,  and  the  sterile  aspirating  needle  is  thrust 
backward  and  a  little  downward  through  this  incision  into  the  bladder.     The 


76 


GENITO-URINARY  SURGERY 


lessened  resistance  will  determine  when  it  has  penetrated  through  all  the  walls 
of  this  viscus  (see  Fig.  45). 

The  bladder  is  partially  or  completely  emptied  in  accordance  with  the 
duration  of  retention  and  the  amount  of  vesical  distention.  The  aspirating 
needle  is  then  withdrawn,  while  suction  is  still  maintained,  thus  preventing 
infection  of  the  needle-track  with  the  urine. 

These  aspirations  may  be  repeated  three  or  four  times  a  day  for  one  or 
two  weeks  without  infecting  the  bladder,  and  usually  without  causing  suppura- 
tion of  the  prevesical  cellular  tissues.     A  few  cases  of  extra-vesical  abscess 


Fig.  45. — Apparatus  for  aspiration  of  bladder.  Con- 
sisting of  a  hypodermic  syringe,  filled  with  1  per  cent,  eucain 
or  some  similar  solution,  narrow  bistoury  for  puncturing 
skin  before  introduction  of  aspirating  needle,  and  small  trocar 
and  cannula  attached  by  means  of  tubing  to  a  bottle  in  which 
a  negative 'pressure  can  be  established  by  means  of  the  pump 
at   the   left    of    the    picture. 

have  been  reported,  when  there  has  been  pronounced  cystitis.  In  prostatic 
retention  incident  to  congestion  and  spasm,  and  in  the  absence  of  infection, 
such  aspiration  may  be  followed  by  a  symptomatic  cure. 

Incomplete  Retention. — The  damage  inflicted  by  incomplete  retention 
upon  the  bladder,  ureters,  and  kidneys  is  commonly  more  pronounced  and 
more  permanent  in  its  effects  than  that  incident  to  complete  retention,  since 
in  the  latter  case  the  symptoms  are  so  urgent  that  relief  is  obtained  by  catheter- 
ization, and  where  needful  a  radical  operation  is  performed,  whilst  in  the  former, 
the  symptoms  being  annoying  rather  than  painful,  there  is  a  progressive,  often 
rapid,  dilatation  of  the  bladder  followed  by  all  the  evil  effects  of  back  pres- 
sure (see  p.  62). 


SUPPRESSION  AND  RETENTION  OF  URINE  77 . 

Patients  suffering  from  incomplete  retention  due  to  prostatic  enlargement 
may  complain  of  no  symptoms  other  than  undue  frequency,  slowness  in  starting 
the  stream,  and  lack  of  propulsive  force.  Acute  prostatic  congestion  aggra- 
vates these  symptoms  and  supplements  them  by  pain  and  tenesmus.  In  the 
early  stages  of  incomplete  chronic  retention,  before  the  bladder  is  markedly 
dilated,  as  determined  by  rectal  and  suprapubic  palpation  and  measurement  of 
the  residual  urine,  the  treatment  of  these  occasional  exacerbations  calls  for 
active  purgation,  hot  normal  saline  enemata,  hot  sitz-baths,  diluents  by  the 
mouth,  a  bland  diet,  and  rest  in  bed.  In  the  absence  of  vesical  infection, 
the  catheter  should  be  omitted  unless  there  is  overdistention,  when  instrumental 
relief  is  imperatively  called  for. 

Treatment  of  Chronic  Incomplete  Retention. — After  the  surgeon  has 
relieved  the  acute  retention  of  prostatics,  has  checked  bleeding,  and  has  cured 
or  alleviated  the  cystitis  from  which  these  patients  usually  suffer,  directions 
must  be  given  which  will  prevent  a  return  of  complete  retention  and  which 
will  keep  the  bladder  in  the  best  condition  to  resist  microbic  invasion  and 
preserve  it  from  the  effects  of  abnormal  tension.  This  necessarily  implies  the 
operative  removal  of  obstruction,  or,  as  a  temporary  measure  and  one  fraught 
with  far  greater  risks  in  so  far  as  the  return  of  health  or  continuance  of  life 
are  concerned,  the  habitual  use  of  a  catheter.  The  catheter  does  not  cause 
vesical  atony  and  cystitis,  but  protects  against  these  sequelae  of  prostatic  enlarge- 
ment; its  use  does  not  abolish  the  power  of  urination,  but  may  restore  it; 
and  it  is  infinitely  better  to  draw  the  water  through  an  instrument  than  to 
pass  it  at  the  expense  of  prolonged  and  violent  straining  efforts. 

The  mechanical  part  of  catheterization  is  learned  by  patients  quickly  enough. 
The  instrument  which  in  each  case  enters  the  bladder  most  readily  and  gives 
least  pain  is  the  best.  This  may  be  a  soft-rubber  catheter,  an  elbowed  or 
double-elbowed  catheter,  the  stiff  English  instrument,  or  exceptionally  even 
the  silver  prostatic  catheter. 

The  number  of  times  the  catheter  is  to  be  passed  during  the  twenty-four 
hours  is  dependent  on  the  renal  activity,  and  the  relief  afforded  to  the  fre- 
quently recurring  and  strongly  persistent  desire  to  urinate.  In  cases  of  mod- 
erate obstruction,  disturbing  only  at  night,  the  passage  of  an  instrument  before 
retiring  is  sufficient.  In  more  pronounced  cases,  with  polyuria  and  both  noctur- 
nal and  diurnal  frequency,  catheterization  may  be  needful  several  times  a  day. 
When  there  is  pronounced  cystitis,  pain  little  if  at  all  relieved  by  the  catheter, 
and  the  symptoms  of  renal  insufficiency,  intermittent  catheterization  is  worse 
than  a  waste  of  time. 

Directions  should  be  given  patients  concerning  the  care  of  instruments  and 
a  cleanly  method  of  using  them.  They  must  be  taught  the  importance  of 
using  sterile  catheters  in  accordance  with  modern  surgical  principles.  This 
is  especially  necessary  when  cystitis  has  not  developed.  The  various  ingenious 
contrivances  in  which  patients  carry  their  instruments — for  instance,  flat  boxes 
and  hollow  canes — are  not  to  be  commended,  since  it  is  almost  impossible  to 
keep  catheters  clean  when  they  are  thus  stored.  Catheterization  is  trouble- 
some at  best,  and  thoroughness  in  carrying  out  antiseptic  details  should  not 
te  sacrificed  to  convenience. 


78  GEXITO-URIXARY  SURGERY 

The  most  comfortable  catheter  having  been  selected,  the  patient  should 
procure  twice  as  many  of  these  as  are  required  in  a  single  day,  a  fresh  instru- 
ment being  used  for  each  catheterization.  Those  of  American  make  are  quite 
as  good  as  the  imported  ones.  In  addition  to  the  catheters  the  patient  must 
secure  a  metal  box  arranged  for  their  sterilization  by  paraform,  tubes  of  anti- 
septic lubricant,  a  bottle  of  tablets  of  mercuric  chloride  for  making  a  solution 
of  1  to  1000  in  which  the  hands  can  be  washed,  a  roll  of  bichloride  gauze,  and 
an  irrigating-bag.  He  should  have  prepared  a  dozen  clean  towels  which  have 
been  boiled  and  sun-dried  or  baked.  The  catheters  are  washed  in  green  soap 
and  hot  boiled  water,  washed  again  in  hot  water,  dried  with  a  clean  towel,  and 
wrapped  each  in  a  piece  of  bichloride  gauze  cut  to  an  appropriate  size.  They 
are  finally  stored  in  the  metal  paraform-box  for  twenty-four  hours  (Fig.  46). 

As  each  catheter  is  required  for  use  it  is  taken  from  the  box,  and,  with  its 
gauze  wrapping  still  unfolded,  is  placed  on  a  clean  towel.  The  patient  then 
fills  his  irrigating-bag  with  a  solution  of  1  to  2000  protargol,  removes  the  cap 
from  the  lubricant  jar,  scrubs  his  hands  thoroughly  with  soap  and  hot  water, 
washes  them  in  bichloride  solution — 1  to  1000 — scrubs  the  glans  penis  with  a 
pledget  of  cotton  dipped  in  this  same  solution,  again  washes  his  hands  in 


Fig.  46. — Box  for  sterilizing  catheters  vrith.  formaldehyde. 

the  bichloride  solution,  unwraps  the  catheter,  dips  it  for  a  moment  in  a  pitcher 
of  hot,  recently  boiled  water,  hot  boric  acid  solution,  or  1  to  20,000  corrosive 
chloride  solution,  to  remove  the  paraform  vapor,  lubricates  it  carefully,  places 
a  clean  towel  around  the  penis,  and  introduces  the  instrument,  attaching  the 
irrigating  apparatus  after  it  has  been  passed  in  four  inches  and  allowing  the 
antiseptic  solution  to  flow  while  the  catheter  is  slowly  pushed  on  into  the  blad- 
der. After  the  bladder  is  emptied,  the  irrigator  is  again  attached  to  the 
catheter  during  its  withdrawal.  The  catheter  thus  used  is  immediately  washed 
and  syringed  out  ^^dth  hot  soapsuds,  is  dipped  for  a  moment  in  boiling  water, 
is  then  shaken  to  dr}'  out  its  interior  as  thoroughly  as  possible,  is  wiped  dry, 
and  is  wrapped  in  a  clean  towel.  At  night  the  hands  are  cleansed,  and  the 
catheters  which  have  been  used  during  the  day  are  again  wrapped  in  bichloride 
gauze  and  put  in  the  paraform-box.  This  box  should  be  provided  with  two 
shelves,  each  containing  enough  catheters  for  twent^-^-four  hours'  use. 

There  are  many  simpler  methods  of  practising  cleanliness  in  catheterization. 
The  method  given  above  is  efficient. 

WTien  it  cannot  be  carried  out,  the  catheters  should  be  boiled  and  wrapped 
in  sterile  towels.  The  hands  and  the  glans  penis  should  be  washed  with 
bichloride  and  the  urethra  should  be  cleansed  by  antiseptic  injections  practised 


SUPPRESSION  AND  RETENTION   OF  URINE  79 

with  an  ordinary  urethral  syringe  before  each  passage  of  the  instrument.  As 
the  latter  is  withdrawn,  the  urethra  should  again  be  flushed  with  the  anti- 
septic. 

When  about  to  travel,  enough  catheters  should  be  sterilized  to  last  at  least 
two  days.  These,  with  the  catheter  case,  lubricant,  antiseptic  towels,  gauze, 
absorbent  cotton,  a  small  basin  for  hand  solution,  and  a  narrow  pint  jar  for 
rinsing  the  formalized  catheter  may  be  packed  in  a  small  valise. 

When  the  above  technique  is  rigidly  enforced,  the  severe  grades  of  traumatic 
urethritis  incident  to  repeated  and  frequent  unclean  catheterization  may  be 
avoided.  When  cystitis  is  present  irrigations  are  extremely  valuable.  A  foun- 
tain syringe  is  used,  and  in  general  a  solution  is  employed  which  does  not 
excite  inflammatory  reaction. 

A  patient  suffering  from  enlarged  prostate  should  also  be  given  careful 
instructions  in  regard  to  the  prophylaxis  of  the  congestive  attacks  which  so 
frequently  cause  acute  retention. 

The  diet  must  be  so  regulated  that  the  urine  shall  be  unirritating.  This 
necessarily  implies  treatment  for  oxaluria,  excess  of  uric  acid,  or  other  ab- 
normal condition.  Diluents  should  be  given  with  the  same  end  in  view,  but 
not  to  the  extent  of  markedly  increasing  the  polyuria  which  is  usually  present. 
The  surface  circulation  should  be  stimulated  by  bathing,  friction,  and  massage. 
Open-air  exercise  is  desirable  for  its  effect  upon  the  general  health.  Even 
horseback  riding  or  the  use  of  a  bicycle  is  sometimes  followed  by  beneficial 
results.     Tonics,  stimulants,  and  nutrients  all  have  their  value. 

As  a  means  of  avoiding  local  congestions,  the  patient  must  be  particularly 
cautioned  against  constipation,  chilling  of  the  surface,  wet  feet,  resisting  the 
desire  to  urinate,  sexual  excess,  indulgence  in  alcohol,  or  overeating.  The 
treatment  directed  to  lessening  the  hypertrophy  is  discussed  under  a  separate 
heading. 

Retention  of   Urine  from  Stricture 

The  retention  of  urine  from  stricture  must  be  distinguished  from  that  de- 
pendent upon  enlarged  prostate,  since  the  treatment  of  the  two  affections  is 
widely  different.  In  both  cases  there  is  usually  a  preceding  history  of  frequent 
urination  with  slowness  in  starting  the  stream.  Prostatics,  however,  have  most 
difficulty  at  night  and  in  the  early  morning.  During  the  day  the  water  flows 
with  comparative  freedom  and  without  much  delay.  Examination  per  rectum 
will  usually  show  enlargement  of  the  prostate.  In  cases  of  stricture  the  fre- 
quency is  most  pronounced  in  the  day,  the  delay  in  starting  the  stream  is  less 
marked,  and  there  is  Hable  to  be  more  dribbling.  Until  retention  is  well 
advanced  there  is  distinct  remission  of  symptoms  at  night.  A  history  of  pre- 
vious gleet  or  of  injury  to  the  perineal  or  the  penile  urethra  is  usually  given. 
It  must  be  recognized  that  sudden  retention  may  develop  in  cases  of  stricture  . 
of  large  calibre  without  a  preceding  history  of  frequency. 

The  diagnosis  is  generally  founded  upon  exploration  of  the  urethra  vnth 
acorn-bougies  and  digital  examination  through  the  rectum. 

There  is  probably  incomplete  retention  in  the  majority  of  tight  strictures. 
but  of  a  degree  insufficient  to  produce  dangerous  vesical  tension.  Any  cause 
of  congestion   and  urethral   spasm,  particularly  sexual  indulgence,   excess  in 


80  GENITO-URINARY  SURGERY 

drink,  chilling  of  the  surface,  or  the  passage  of  a  catheter,  may  make  the 
retention  complete.  This  form  of  complete  retention  is,  however,  of  short 
duration. 

Treatment. — Since  the  bladder  has  a  tendency  to  become  hypertrophied 
rather  than  dilated,  it  is  rare  in  the  case  of  stricture  to  find  it  enormously  dis- 
tended. Even  when  the  tension  is  still  moderate,  the  suffering  is  so  intoler- 
able that  the  help  of  the  surgeon  is  demanded.  Since  spasm  and  congestion 
play  the  major  role,  a.  hot  bath,  hot  enemata,  opium  and  belladonna  supposi- 
tories, and  hot  turpentine  stupes  over  the  hypogastrium  may  be  tried.  If 
these  measures  fail,  the  surgeon  should  promptly  proceed  to  instrumentation. 
On  the  chance  of  the  stricture  being  of  large  calibre  and  of  the  retention  being 
caused  mainly  by  muscular  spasm,  an  effort  may  be  made  to  introduce  a  steel 
sound,  16  to  20  F.,  into  the  bladder.  If  this  fails,  fine  conical  and  rat-tailed 
soft  catheters  should  next  be  tried.  These  failing,  filiform  whalebone  bougies 
should  be  used,  and  gently  manipulated  till  one  enters  the  bladder.  When  the 
filiform  has  entered  the  distended  bladder,  it  may  be  tied  in  place,  with  the 
full  assurance  that  enough  urine  will  leak  out  beside  it  to  relieve  tension,  and 
that  the  stricture  will  be  sufficiently  softened  to  allow  of  the  passage  of  larger 
instruments;  or  a  Gouley's  catheter  may  at  once  be  passed  over  the  filiform  as 
a  guide.  When  a  woven  filiform  bougie  can  be  passed  the  most  useful  type  of 
catheter  is  that  of  Phillips,  which  is  threaded  at  the  tip  to  screw  into  the  base 
of  the  filiform.  In  use  the  filiform  is  pushed  ahead  of  the  catheter,  and  coils 
up  in  the  bladder  (Fig.  4). 

WTien  a  filiform  cannot  be  passed,  aspiration,  by  relieving  tension  and 
congestion  and  relaxing  spasm,  will  at  times  be  followed  by  success  on  subse- 
quent efforts  to  pass  instruments  through  the  urethra.  Usually  on  failure  to 
pass  any  instrument  external  urethrotomy  is  required. 

Retention  of  Urine  from  Traumatism 

Under  this  heading  is  included  that  form  of  retention  which  follows  direct 
injury  of  the  urethra  or  the  bladder.  Retention  following  general  trauma,  such 
as  that  observed  in  the  aged  after  luxation  of  the  hip  or  fracture  of  the  thigh, 
is  probably  due  to  disordered  reflexes  (inhibition  of  the  detrusors  or  ^asm 
of  the  sphincters),  and  is  elsewhere  described. 

Rupture  of  the  bladder  may  cause  retention,  partly  because  the  urine 
escapes  through  the  rent,  partly  from  muscular  palsy.  Laceration  or  rupture 
of  the  urethra  always  causes  retention.  The  symptoms  and  treatment  of  these 
injuries  will  be  considered  under  separate  headings.  The  general  indications 
are  immediate  closure  of  the  rupture  and  drainage  of  the  bladder  by  continuous 
catheterization  or  by  the  perineal  drainage-tube. 

INCONTINENCE  OF  URINE 

Incontinence  of  urine  results  from  inability  of  the  sphincters  to  prevent 
the  escape  of  urine  from  the  bladder,  and  is  characterized  by  the  involuntary, 
sometimes  the  unconscious,  escape  of  urine.  Guyon  distinguishes  as  true  incon- 
tinence that  in  which  the  urine  escapes  without  previous  urgency  or  even 
desire,  thus  excluding,  for  instance,   those  cases  of  prostatocystitis  in  which 


SUPPRESSION  AND  RETENTION  OF  URINE 


81 


the  desire  is  so  imperious  and  irresistible  that  the  patient  cannot  withstand 
it.     He  thus  tabulates  true  incontinence: 


Incontinence. 


Without  material 
lesions  of  the 
urinary  tract. 


With  material  le- 
sions of  the  uri- 
nary tract. 


Incontinence  from  nerve-lesions. 

Incontinence  from  nervous  affections.  ' 

Incontinence  of  children. 

f  Mechanical  incontinence. 
I  Incontinence  of  tuberculosis. 
Without  retention  -j  Traumatic  incontinence. 

of  urine  Incontinence    from    urethral    in- 

sufficiency, 
f  Incontinence  of  stricture. 
With  retention  of  \  Incontinence    of    enlarged    pros- 
urine.  [      tate. 


Incontinence  Without  Lesions  of  the  Urinary  Tract 

Incontinence  due  to  nerve  lesion  is  usually  preceded  by  retention,  the  urine 
escaping  drop  by  drop  from  the  overfull  bladder.  The  conditions,  such  as  the 
palsies  and  degenerations,  which  occasion  this  retention  have  been  already 
mentioned.  The  appropriate  treatment  is  regular  aseptic  evacuation  of  the 
bladder. 

Incontinence  of  nervous  affections  often  appears  in  the  form  of  an  uncon- 
scious escape  of  urine  from  the  bladder,  which  is  never  overdistended.  Hysteria, 
neurasthenia,  incipient  diabetes,  and  epilepsy  occasion  this  form  of  inconti- 
nence. 

Epileptic  incontinence  is  of  special  interest,  since  it  may  be  the  only  symp- 
tom to  excite  suspicion  of  the  nervous  affection.  Trousseau  states  that  adults 
who,  without  lesion  of  the  urethra  or  bladder,  wet  their  beds  at  night  should 
be  suspected  of  epilepsy.  In  these  cases  suspicion  as  to  epilepsy  having  been 
excited,  will  lead  to  the  detection  of  other  symptoms,  which  may  justify  a 
positive  diagnosis.  In  hysteria  and  neurasthenia  the  condition  is  rare.  Any 
violent  emotion,  particularly  fright,   may  occasion  this  form  of  incontinence. 

Incontinence  of  children  is  essentially  a  functional  disease.  It  usually 
begins  about  the  fourth  or  fifth  year,  but  sometimes  is  continued  from  early 
infancy.  There  is  a  natural  tendency  towards  cure  at  the  period  of  puberty, 
but  many  cases  persist  beyond  this  time.  It  is  almost  invariably  nocturnal. 
Exceptionally  it  is  both  nocturnal  and  diurnal.  The  cause  of  this  incontinence 
is  unknown.  Heredity  is  a  distinctly  predisposing  factor.  The  possibility  of 
epilepsy  as  an  etiological  factor  should  always  be  carefully  considered. 

Trousseau  classifies  this  affection  as  a  neurosis,  characterized  by  excessive 
irritability  and  exaggerated  tonicity  of  the  vesical  muscles.  Perhaps  the  most 
satisfactory  explanation  is  that  which  attributes  this  perversion  of  function 
to  an  increased  irritability  of  the  prostatic  urethra.  In  cases  of  posterior  urethri- 
tis, because  of  the  increased  sensibility  of  the  prostatic  urethra,  the  moment  the 
internal  vesical  sphincter  yields  and  allows  the  urine  to  reach  this  inflamed 
mucous  membrane,  the  desire  to  urinate  is  urgent,  imperative,  and  often 
irresistible.  In  the  case  of  a  child  with  a  hypersesthetic  posterior  urethra,  and 
with  spinal  reflexes  much  more  readily  excited  than  in  adults,  particularly 
during  sleep,  the  escape  of  the  first  few  drops  of  urine  into  the  prostatic  urethra 
is  probably  sufficient  to  set  in  active  operation  the  nervous  and  muscular 
mechanism  of  micturition.  During  the  day  cerebral  control  is  usually  able 
6 


82  •    GEXITO-URIXARY  SURGERY 

to  inhibit  this  reflex,  but  when  the  prostatic  urethra  is  particularly  irritable 
the  reflex  is  excited  so  suddenly  that  urination  takes  place  before  the  child  has 
time  to  control  it  by  a  conscious  effort. 

.  Diagnosis. — Before  deciding  that  a  child  who  wets  his  bed  at  night  or 
soils  his  clothing  in  the  daytime  is  suffering  from  a  purely  functional  trouble, 
diabetes,  poKnaria,  vesical  tuberculosis,  cystitis,  nephritis,  calculus,  and  foreign 
body  must  be  eliminated.  If  the  urine  is  perfectly  normal,  and  is  not  excessive 
in  quantity,  and  if  urination  is  painless  and  is  normally  accomplished,  these 
various  causes  of  incontinence  can  be  eliminated.  Epilepsy  must  be  excluded 
by  ha\ing  the  child  watched  through  several  nights. 

Treatment. — Since  incontinence  in  children  is  often  due  to  an  exaggerated 
reflex,  a  careful  search  must  be  made  for  any  abnormality  which  may  indi- 
rectly lead  to  such  increased  reflex  excitability.  Thus,  the  anus  and  the  rectum 
should  be  examined  for  poh-p,  eczema,  fissure,  or  seat-worms.  The  urethra 
should  be  explored  for  narrowings  or  valvular  formations,  and,  since  most  chil- 
dren are "  phimotic,  it  is  well  on  general  principles  to  practise  circumcision. 
This  in  itself  is  often  curative.  Errors  of  diet  must  be  carefully  corrected,- 
and  the  urine  rendered  bland  b}^  gi^'ing  water  and  milk  in  abundance.  Liquids 
should  not,  however,  be  given  in  the  evening.  The  total  quantity  of  urine 
passed  in  twenty-four  hours  should  be  measured.  This  may  show  that  the 
incontinence  is  really  due  to  over-distention,  the  patient  secreting  during  the 
night  more  urine  than  the  bladder  can  retain. 

The  general  system  should  be  strengthened  by  exercise  in  the  open  air, 
regular  bathing,  massage  in  the  case  of  ver\^  weak  children,  and  the  admin- 
istration of  tonics.  Compound  syrup  of  hypophosphites  in  doses  suited  to  the 
age  is  particularly  serviceable.  It  is  well  to  encourage  the  child  in  the  habit  of 
defecating  immediately  before  bedtime.  This  end  may  be  accomplished  by 
the  regular  use  of  enemata.  If  the  examination  of  the  urine  shows  oxalates 
or  other  sediments  in  excess,  the  appropriate  dietetic  regulations  should  be 
enforced. 

It  sometimes  happens  that  a  habit  of  nocturnal  incontinence  is  due  orig- 
inally to  carelessness.  The  child,  though  awakened  by  the  desire  to  urinate, 
prefers  wetting  his  bed  to  getting  up.  Shortly  he  is  so  imperfectly  awakened 
that,  though  micturition  is  partially  volitional,  he  is  practically  unconscious 
of  the  act.  It  will  be  found  that  the  urine  is  passed  at  about  the*  same  hour 
every  night.  If  the  nurse  is  directed  to  inspect  the  child  hourly  for  two  or 
three  nights,  the  time  of  semiconscious  urination  may  be  determined. 

In  these  cases  a  cure  may  be  accomplished  by  having  the  child  waked  at 
about  one  or  two  in  the  morning,  or  an  hour  before  his  habitual  time  of  involun- 
tary micturition,  and  made  to  empty  his  bladder. 

As  further  means  of  lessening  the  tendency  to  nocturnal  enuresis,  the  appli- 
cation of  a  bandage  about  the  waist  of  the  child,  with  a  projection  in  the 
back  so  that  he  is  compelled  to  lie  on  his  side,  sleeping  on  a  comparatively 
hard  bed  with  covering  just  sufficient  for  necessary  warmth,  the  elevation  of 
the  foot  of  the  bed,  and  counter-irritation  in  the  form  of  blisters  over  the  lumbar 
spine,  have  been  tried  with  apparently  satisfactory  results. 

Medical  Treatment. — The  drugs  administered  for  the  cure  of  enuresis  in 
children  are  belladonna,  atropine,  hyoscine  or  hyoscyamine',  potassium  bromide, 
quinine,  and  thyroid  extract. 


SUPPRESSION  AND  RETENTION  OF  URINE  83 

Belladonna,  the  drug  upon  which  reliance  has  been  chiefly  placed,  is  ad- 
ministered in  ascending  doses  until  either  the  physiological  effect  is  obtained 
or  the  incontinence  is  cured.  This  drug  is  pushed  to  the  hmit  of  safety; 
thus,  a  child  four  years  old  may  be  given  an  eighth  of  a  grain  of  belladonna 
extract,  four  drops  of  the  tincture,  or  one  to  two  minims  of  the  fluid  extract 
of  the  root  in  the  evening.  Or  the  drug  may  be  given  in  the  form  of  sup- 
pository, the  dose  then  being  slightly  larger.  Good  results  are  often  secured 
by  administering  atropine  in  increasing  doses  up  to  the  limit  of  tolerance.  A 
solution  of  atropine,  one  grain  in  two  ounces  of  water,  may  be  prescribed,  so 
that  one  drop  contains  approximately  one-thousandth  part  of  a  grain.  Two  to 
three  drops  three  times  a  day  should  be  given,  the  dose  being  increased  by 
one  drop  every  day  or  two  till  the  enuresis  is  controlled  or  toxic  symptoms 
develop.  Hyoscine  or  hyoscyamine  may  be  employed  in  doses  of  the  two- 
hundred-and-fiftieth  of  a  grain;  potassium  bromide,  five  to  fifteen  grains;  qui- 
nine, two  to  ten  grains.  Thyroid  extract,  in  doses  of  one-fourth  to  one  grain 
three  times  a  day,  sometimes  produces  a  prompt  cure  of  the  condition. 

If  the  desired  result  is  not  quickly  accomplished,  no  benefit  is  obtained  by 
continuing  these  remedies.  Should  the  enuresis  be  apparently  cured,  the  dose 
should  be  gradually  lessened.  If  there  is  temporary  relief  followed  by  relapse, 
the  dose  may  be  cautiously  increased.  Quinine  has  been  particularly  com- 
mended by  Potts,  on  the  theory  that  enuresis  is  probably  caused  in  the  greater 
number  of  cases  by  failure  of  the  higher  centres  to  control  properly  the  reflex 
act  by  which  the  bladder  is  emptied.  Quinine  was  given  in  full  doses  as  a 
stimulant  to  the  inhibitory  centre,  with  strikingly  satisfactory  results  in  the  few 
cases  in  which  it  was  tried. 

Mechanical  Treatment. — This  may  be  applied  in  the  form  of  (1)  sounds, 
(2)  electricity,  (3)  instillations,  (4)  epidural  or  presacral  injections.  Its  ob- 
ject is  to  relieve  the  hyperaesthesia  and  congestion  of  the  prostatic  urethra  and 
to  stimulate  the  sphincter  muscle. 

The  passage  of  a  cold  steel  sound  of  such  size  that  it  enters  the  bladder 
■v\'ithout  the  employment  'of  force  is  usually  efficacious.  This  sound  should  be 
left  in  place  for  from  three  to  five  minutes,  and  should  be  passed  every  third 
or  fourth  day. 

If  after  three  weeks  of  sounding  and  a  fourth  week  of  rest  symptoms  are 
not  improved,  electricity  should  be  employed.  This  is  applied  by  means  of 
a  urethral  electrode  (Fig.  47)  vulcanized  to  within  an  inch  of  its  extremity, 
shaped  hke  a  sound,  and  with  the  rather  sharp  curve  appropriate  to  the  urethra 
of  children.  The  electrode  is  passed  into  the  urethra  until  its  metal  extremity 
lies  within  the  membranous  and  prostatic  portions  of  this  canal.  It  is  then 
attached  to  the  faradic  batterj.',  the  other  electrode  of  which  is  applied  over 
the  perineum  or  to  the  lumbar  spine.  The  patient  is  given  fifty  slow  interrup- 
tions, the  current  being  so  regulated  that  it  does  not  cause  pain.  The  treatment 
is  repeated  every  three  or  four  days.  The  rectal  electrode  is  less  painful  and 
nearly  as  efficacious. 

If  in  three  or  four  weeks  electrical  treatment  does  not  improve  or  cure  the 
enuresis,  instillations  of  silver  nitrate  may  be  employed.  From  three  to  five 
drops  of  a  two  to  five  per  cent,  solution  are  injected  into  the  membranous 
or  prostatic  urethra  not  more  than  tvirice,  a  week  elapsing  before  the  second 
application. 


84 


GENITO-URINARY  SURGERY 


Should  the  incontinence  still  persist,  epidural  or  retro-rectal  injections  may- 
be tried. 

The  epidural  injection  is  made  into  the  space  between  the  dura  and  the 
periosteal  lining  of  the  vertebral  canal.    About  one  or  two  centimetres  (.4  to  .8 
of  an  inch)  above  the  intergluteal  fold,  is  the  flat  triangular 
sacrococcygeal  space,  the  upper  limit  or  base  being  formed  by 
the  convex  bulging  ridge  of  the  last  sacral  vertebra  terminat- 
ing at  the  lateral  sacral  cornua.     The  distance  between  this 
space  and  the  tip  of  the  coccyx  is  about  six  and  one-half  to  seven 
centimetres   (two  and  one-half  to  three  inches).     In  stout  indi- 
viduals digital  exploration  will  be  necessary  to  determine  the  exact 
location  of  this  space.     Its  mid-portion  is  the  best  site  for  the 
injection.    Through  a  skin  puncture  made  under  local  anaesthesia 
by  a  sharp-pointed  tenotome  the  needle  should  be  inserted  to  a 
depth  of  one  and  one-half  to  two  inches    (three  to  five  centi- 
metres) in  the  mid-line  (to  avoid  injury  to  the  coccygeal  nerves 
or  ganglia)  and  in  a  forward  and  upward  direction.    i\s  the  sacro- 
coccygeal ligament  is  punctured,  its  density  is  readily  appreciated, 
and  thereafter  the  tissues  hold  the  needle  somewhat  rigidly. 

From  five  to  twenty  cubic  centimetres  of  normal  salt  solution 
may  be  given  three  times  a  week.  Some  cases  require  repeated 
injections.  A  remarkable  feature  in  the  reported  results  of  this 
treatment  is  that  excessive  desire  to  urinate  is  said  to  be  dimin- 
ished and  deficient  desire  to  be  stimulated.  The  operation  is 
rarely  painful  and  the  treatment  if  carried  out  as  above  described 
is  not  likely  to  do  harm. 

Jaboulay  commends  retrorectal  injections  as  simpler  in  adminis- 
tration and  even  more  efficacious.  The  needle  is  introduced  at 
the  tip  of  the  coccyx  and  passed  vertically  upward  for  two  inches, 
a  finger  in  the  rectum  guarding  this  portion  of  the  bowel  against 
puncture.  Two  hundred  cubic  centimetres  of  normal  salt  solution 
are  slowly  injected  in  adults — about  quarter  the  quantity  in 
children.  Some  extraordinary  cures  are  reported,  the  cures  being 
explained  on  the  basis  of  a  mechanical  impression  on  the  hypo- 
gastric plexus.  Should  this  method  fail,  recourse  must  be  had  to 
the  local  application  of  electricity,  and  this  should  be  continued 
over  a  long  period — from  six  to  eight  months,  or  even  a  year. 

If  the  enuresis  is  purely  functional,  many  children  will  get 
well,  after  attention  to  their  general  hygiene,  if  they  abstain 
from  liquids  in  the  evening,  empty  the  bowels  and  bladder 
before  going  to  bed,  and  rise  once  during  the  night  to 
micturate. 

Though  it  is  customary  to  advise  as  the  next  means  of  treatment  the 
administration  of  drugs,  we  are  in  general  opposed  to  this,  believing  that  results 
are  more  promptly  attained  by  local  treatment,  provided  the  attendant  is 
fairly  skilful  in  the  use  of  urethral  instruments  and  recognizes  the  importance 
of  thorough  cleanliness  in  all  his  manipulations. 


Fig.  47.— Ure- 
thral electrode. 


SUPPRESSION  AND  RETENTION  OF  URINE  85 

When  enuresis  has  lasted  past  the  age  of  puberty,  the  best  results  will 
be  obtained  from  the  use  of  full-calibre  sounds,  instillations,  and  possibly  from 
epidural  or  presacral  injections. 

Incontinence  with  Lesions  of  the  Urinary  Tract 

When  enuresis  is  not  functional^  but  is  due  to  hypersecretion  or  to  tubercu- 
losis, for  instance,  the  cause  must  receive  treatment. 

Incontinence  without  retention  of  urine  is  necessarily  dependent  upon  a 
patulous  condition  of  the  sphincter.  This  may  be  caused  by  lodgement  of 
an  irregularly  shaped  stone,  by  which  the  vesical  sphincter  is  kept  open  but 
is  not  occluded.  This  form  of  incontinence,  Guyon  states,  is  observed  only 
in  children. 

Such  a  condition  should  be  treated  by  pushing  the  stone  back  into  the 
bladder  and  removing  it  by  litholapaxy,  or,  in  case  this  is  impossible,  by 
perineal  section. 

Tuberculous  ulceration  may  infiltrate  and  entirely  destroy  the  vesical  sphinc- 
ters, resulting  in  an  intractable  form  of  incontinence,  the  nature  of  which  is 
rarely  doubtful,  since  it  develops  only  in  the  advanced  stage  of  vesical  tuber- 
culosis. 

Incontinence  due  to  contusion  or  overstretching  of  the  sphincter,  such  as 
occurs  in  perineal  lithotrity  or  in  digital  examination  of  the  female  bladder 
through  the  urethra,  may  persist  indefinitely.  Tonicity  of  the  sphincter  muscle 
is  best  restored  by  the  local  application  of  electricity. 

Incontinence  due  to  fistulous  opening  of  the  bladder  is  elsewhere  discussed. 
Guyon  describes  under  the  heading  urethral  insufficiency  a  form  of  in- 
continence characterized  by  involuntary  escape  of  urine  caused  by  the  slight- 
est muscular  effort,  such  as  coughing,  laughing,  or  straining,  or  even  by 
standing.  The  urethra  is  perfectly  normal.  Women  especially  suffer  from 
this  form  of  incontinence,  because  of  atonicity  of  the  vesical  sphincter.  Some- 
times it  is  seen  in  men.  after  stretching  of  the  prostatic  urethra  or  the  use  of 
very  large  sounds. 

Electricity  supplemented  by  instillations  is  serviceable  in  these  cases.  In 
women,  when  this  method  of  treatment  fails  and  the  escape  of  urine  is  profuse, 
as  a  last  resort  the  urethra  may  be  freed  by  dissection  through  the  greater 
part  of  its  length,  given  a  half  or  a  three-fourths  twist  in  its  long  axis,  and 
sewed  in  this  position. 

Incontinence  of  retention  is  the  ordinary  form  of  incontinence,  and  is 
observed  particularly  in  those  suffering  from  enlarged  prostate  or  from  stric- 
ture. Distinction  should  be  made  between  this  form  of  incontinence,  in  which 
the  urine  dribbles  without  either  the  volition  or  the  consciousness  of  the  patient, 
and  the  urgent,  imperious  urination  of  cystitis  or  of  irritable  bladder.  The 
true  nature  of  this  incontinence  is  of  course  at  once  recognized  by  vesical  palpa- 
tion, and  the  nature  of  the  obstruction  is  determined  by  the  previous  history 
and  by  urethral  examination. 

When  in  this  form  of  incontinence  the  urethra  is  patulous  and  is  of  normal 
length,  the  cause  must  be  sought  in  the  nervous  system. 

As  for  treatment,  this  is  directed  to  the  relief  of  the  retention  rather  than 
to  the  incontinence,  and  has  been  already  discussed. 


CHAPTER  VII 

BACTERIN  AND  SERUM  THERAPY 

As  the  mode  of  action  of  the  tissues  of  the  bodyj  in  combating  infections 
has  become  better  understood,  certain  biological  methods  have  been  evolved 
to  increase  and  direct  their  activity. 

Two  quite  different  methods  are  available.  By  the  use  of  bacterins,  or 
vaccines  (the  various  tuberculins  being  here  included  in  the  term  for  the  sake 
of  convenience),  the  tissues  are  stimulated  to  the  production  of  bodies  inimical 
to  the  bacteria;  by  the  use  of  sera  substances  inimical  to  the  bacteria  are 
added  to  the  body.  Therefore  the  object  of  bacterin  therapy  is  to  produce 
an  active  resistance,  while  the  administration  of  sera  is  for  the  purpose  of  con- 
ferring a  passive  immunity.  The  selection  of  the  remedy  to  be  employed 
depends  in  part  on  the  condition  of  the  patient  and  the  effect  desired,  and  in  part 
on  the  availabiUty  of  the  desired  preparation. 

BACTERINS 

Bacterins  are  suspensions  of  killed  bacteria,  so  made  that  the  preparations 
are  of  a  convenient  strength  for  hypodermic  administration.  An  antiseptic  is 
usually  added. 

The  purpose  of  the  administration  of  bacterins  is  to  increase  the  natural 
bactericidal  power  of  the  body  against  the.  particular  infecting  germ.  This 
bactericidal  power  lies  in  what  are  known  as  antibodies,  or  as  immune  bodies 
when  they  are  produced  specifically  against  a  particular  antigen  (the  infecting 
bacterium). 

These  immune  bodies  are  of  various  kinds,  the  kinds  varying  with  the 
requirements  of  the  body  in  meeting  the  attack  of  ,the  particular  infecting  germ. 
.\ntitoxins  neutralize  the  poisons  generated  by  the  bacteria.  Agglutinins  cause 
certain  motile  bacteria,  as  the  t^/phoid  bacillus,  to  lose  their  motility  and  be- 
come clumped.  Lysins,  or  bacteriolysins,  immune  bodies  of  great  practical 
importance,  cause  the  solution  of  bacteria.  Opsonins  are  constituents  of  the 
blood-plasma  which  prepare  the  bacteria  for  phagocytosis  by  the  leucocytes. 
Except  bacteria  be  acted  upon  by  opsonins,  their  ingestion  by  the  leucocytes 
is  negligible. 

The  hypodermic  administration  of  bacteria  in  appropriate  dose  causes  an 
increment  in  the  production  of  all  these  immune  bodies,  but,  on  account  of 
the  comparatively  greater  ease  with  which  it  can  be  determined,  the  increase 
or  decrease  in  opsonic  activity  is  usually  taken  as  the  measure  of  bacterial 
resistance. 

The  Opsonic  Index. — The  consumption  of  bacteria  by  the  leucocytes  is 
proportional  to  the  activity  of  the  opsonins  which  act  on  these  microorganisms, 
preparing  them  for  leucocytic  phagocytosis.  The  opsonic  index,  one  of  the 
ways  of  estimating  the  effect  of  bacterin  therapy,  is.  a  comparison  of  the  phago- 
cytic power  of  leucocytes  upon  bacteria  acted  upon  by  the  patient's  serum  (that 
is,  the  patient's  opsonins)  -with  the  activity  of  these  cells  when  serum  from  a 
normal  person  is  used  in  the  experiment.  The  index  is  obtained  by  dividing 
86 


BACTERIN  AND  SERUM  THERAPY  87 

the  number  of  bacteria  found  within  a  certain  number  of  leucocytes  when 
the  patient's  serum  is  used  by  the  number  in  an  equal  number  of  leucocytes 
when  normal  serum  is  employed.  Therefore  if  the  patient's  opsonic  poWer  be 
less  than  normal,  the  index  is  less  than  1,  as  0.75,  while  if  it  be  greater  than 
normal  the  index  is  greater  than  1,  as  1.25. 

After  a  bacterial  injection  there  is  commonly  a  drop  in  the  index,  followed 
by  a  rise.  The  drop  is  spoken  of  as  the  negative  phase,  and  when  well  marked 
is  evidenced  clinically  by  lassitude,  headache,  loss  of  appetite,  bodily  aches, 
rise  of  temperature,  occasionally  a  chill,  and  inflammatory  reaction  in  the 
affected  region  and  at  the  site  of  injection;  the  rise  is  spoken  of  as  the  positive 
phase,  and  is  denoted  clinically  by  progressive  improvement  in  the  local  condi- 
tion. The  object  striven  for  in  the  treatment  is  to  incur  as  slight  a  negative 
phase  as  possible,  while  inducing  a  well-marked  positive  phase.  Practically, 
it  is  usually  possible  to  treat  a  case  in  a  thoroughly  satisfactory  manner  with- 
out resorting  to  the  rather  laborious  technique  of  the  estimation  of  the  opsonic 
index. 

Immune  bodies  are  specific  for  the  bacterium  used  as  antigen,  and  for  that 
particular  strain  of  that  bacterium.  It  is  therefore  essential  in  selecting  a 
bacterin  preparation  to  have  one  containing  the  infecting  organism.  In  some 
cases  this  can  be  satisfactorily  accomplished  by  using  a  vaccine  containing 
a  large  number  of  strains.  However,  the  utilization  of  mixed  bacterins,  and 
even  of  polyvalent  preparations,  necessarily' is  accompanied  by  the  performance 
of  much  useless  work  on  the  part  of  the  tissue-cells  in  producing  unneeded 
immune  bodies,  so  that  for  this  reason,  as  well  as  because  of  the  'greater  cer- 
tainty of  obtaining  the  proper  organism,  autogenous  bacterins  (that  is,  those 
prepared  by  culturing  the  germ  infecting  the  patient  to  be  treated)  are  to  be 
preferred  to  the  stock  article  made  up  from  cultures  obtained  from  other 
sources. 

Yet  in  the  case  of  certain  organisms  difficult  of  culture,  as  the  gonococcus 
and  the  tubercle  bacillus,  the  use  of  stock  preparations  is  the  only  practical 
one,  and  usually  gives  satisfactory  results. 

Dosage. — The  more  virulent  the  organism,  and  the  more  frail  and  sick 
the  patient,  the  smaller  should  be  the  initial  inoculation,  and  the  more  cautious 
the  increase  in  subsequent  doses,  which  are  usually  given  at  intervals  of  from 
three  days  to  a  week. 

To  be  more  explicit,  the  initial  dose  of  such  organisms  as  the  Streptococcus, 
the  Gonococcus,  the  Bacillus  of  Friedldnder,  and  the  Bacillus  coli  should  be 
small,  from  5  to  50  million.  The  first  dose  of  the  Staphylococcus,  the  M. 
catarrhalis,  B.  pseudotuberculosis  rodentium,  etc.,  may  be  from  25  to  100 
million.  If  the  first  dose  causes  no  reaction,  the  second  may  be  twice  as 
great,  the  third  double  the  second,  the  fourth  three  times  the  second,  the  fifth 
four  times  the  second,  and  so  on.  If  any  of  these  injections  should  give  rise 
to  a  reaction,  the  next  dose  must  not  be  given  till  this  has  entirely  subsided, 
and  must  be  no  larger,  generally  smaller,  than  the  dose  which  caused  the  dis- 
turbance. Otherwise  the  dosage  may  be  steadily  increased  till  500  to  1000 
million  are  being  given,  and  the  patient  is  proceeding  in  a  satisfactory  manner. 
Determinations  of  the  opsonic  index  from  time  to  time,  when  this  is  feasible, 
are  of  much  value  in  determining  when  inoculations  should  be  discontinued, 
by  showing  the  attainment  of  a  satisfactory  degree  of  immunity. 


88  GENITO-URINARY  SURGERY 

It  is  also  to  be  remembered  that  a  diseased  condition  may  be  due  to  more 
than  one  bacterium,  and  that  one  bacterium  may  disappear  and  another  take 
its  place  during  the  course  of  treatment.  It  is  therefore  desirable  that  re- 
peated cultures  be  made  when  patients  do  not  improve  in  an  entirely  satis- 
factory manner. 

Indications, — Bacterin  therapy  is  particularly  indicated  in  subacute  and 
chronic  localized  infections.  When  the  infection  is  acute  there  is  usually  suffi- 
cient absorption  to  cause  an  abundant  elaboration  of  immune  bodies  if  the 
tissues  are  capable  of  responding  to  the  stimulus,  and  a  therapeutic  injection 
is  apt  to  increase  the  already  existent  negative  phase. 

Bacterin  therapy  is  to  be  considered  as  an  adjuvant  to  surgical  treatment; 
rarely  is  it  a  substitute  therefor.     Its  uses  may  be  summarized  as  follows: 

Bladder  and  Kidney. — In  cystitis,  pyelitis,  and  to  a  less  extent  in  pyelone- 
phritis and  in  pyonephrosis,  bacterins  are  of  value.  Organisms  which  have 
been  isolated  are  the  Bacilli  coli,  tuberculosis^  pseudotuberculosis  rodentium, 
acidi  lactici,  typhosus,  the  Bacillus  of  Friedlander,  the  Corynebacterium  pseudo- 
dip  ht  her  it  icum,  Streptococci  pyogenes,  and  Septicemia  hccmorrhagica,  staphylo- 
cocci, gonococcus,  and  micrococcus  lanceolatus. 

Prostate  and  Seminal  Vesicles. — Though  the  gonococcus  is  the  usual  pri- 
mary cause  of  inflammation  of  these  organs,  this  organism  has  associated  with 
it  other  bacteria  at  a  comparatively  early  stage  of  the  disease,  the  added  in- 
fection coming  either  from  the  urethra  or  through  the  blood.  Immunization 
must  therefore  consist  in  the  administration  of  gonococcus  bacterin,  usually  a 
stock  preparation  made  up  from  several  strains,  and  an  autogenous  vaccine, 
made  up  by  culturing  the  expressed  secretions. 

Among  the  organisms  which  have  been  found  are  the  Micrococci  aureus, 
albus,  citreus,  candicans,  candidans,  and  orbicularis,  the  Bacilli  typhosus,  pyo- 
cyaneus,  and  acidi  lactici,  and  the  Corynebacterium  pseudodiphtheriticum.  New 
cultures  must  be  made  from  time  to  time,  and  fresh  bacterins  prepared  as  the 
bacterial  flora  changes. 

Epididymitis. — In  the  acute  stages  antigonococcus  serum  is  indicated 
rather  than  bacterin;  the  latter  (gonococcus)  may  be  used  in  cases  show- 
ing a  tendency  to  run  a  protracted  course,  with  frequent  recurrences. 

Urethritis. — The  results  of  bacterin  treatment  of  gonorrhoeal  urethritis 
have  not  been  encouraging.  However,  Laird  *  has  found  that  the  use  of  auto- 
genous bacterins,  not  of  the  gonococcus  but  of  the  other  organisms  found  in 
the  discharge,  materially  lessens  the  intensity  of  the  posterior  symptoms,  and 
the  duration  of  such  complications  as  prostatitis  and  vesiculitis. 

Vulvovaginitis,  in  young  children,  is  better  treated  by  bacterins  than  by 
local  applications.  In  the  acute  cases  a  polyvalent  gonococcus  bacterin  should 
be  used;  the  initial  dose  of  about  5  million  should  be  cautiously  increased  at 
intervals  of  from  four  to  seven  days  till  50  or  100  million  are  given.  In 
the  chronic  cases  it  is  often  useful  to  supplement  the  gonococcus  preparation 
with  autogenous  bacterins  containing  organisms  which  have  become  associated 
with  the  gonococcus. 

In  older  girls   (that  is,  those  over  ten  or  fourteen  years)    and  in  women 
bacterins  seem  to  have  little  or  no  effect. 
♦Personal  communication. 


BACTERIN  AND  SERUM  THERAPY  89 

TUBERCULIN 
Tuberculin  may  be  used  both  as  a  diagnostic  and  as  a  therapeutic  agent. 

Tuberculin  in    Diagnosis 

Two  principal  methods  are  employed,  the  subcutaneous  method  of  Koch, 
and  von  Pirquet's  method  by  scarification.  In  both  methods  Koch's  Old  Tuber- 
culin ("O.  T."),  a  filtrate  of  a  concentrated  bouillon  culture  of  tubercle  bacilli, 
containing,  therefore,  the  toxins  of  the  bacteria,  is  used. 

The  subcutaneous  method  is  the  one  usually  to  be  preferred,  as  with  it, 
by  the  focal  reaction,  it  is  possible  to  be  assured  that  the  lesion  of  which 
the  patient  complains  is  the  one  producing  the  reaction,  and  that  some  unsus- 
pected, inactive  lesion  is  not  responsible. 

It  is  customary  to  observe  the  patient  for  some  days  before  the  test  is 
applied,  having  the  temperature  taken  at  frequent  intervals  to  ascertain  its 
usual  variations.  The  test  is  not  applicable  in  patients  running  a  marked  febrile 
course,  in  general  miliary  tuberculosis,  acute  or  advanced  phthisis,  tuberculous 
meningitis,  or  in  markedly  asthenic  individuals  or  convalescents  from  acute  ill- 
ness; in  the  latter  conditions  a  reaction  may  not  be  produced.  Under  the  cir- 
cumstances mentioned  the  von  Pirquet  reaction  should  be  selected. 

A  dose  of  0.5  milligramme  (0.05  mg.  in  children)  is  first  given.  A  posi- 
tive reaction  is  understood  to  consist  in  a  rise  of  temperature  of  at  least  one 
degree  Fahrenheit,  an  increase  in  symptoms  (focal  reaction),  and  usually  some 
irritation  at  the  site  of  injection  (local  reaction).  If  no  reaction  is  produced, 
successive  doses  of  1.25  mg.,  2.5  mg.,  and  5.0  mg.  in  adults  and  0.2  mg.,  0.5  mg., 
and  1.0  mg.  in  children  are  given  at  intervals  of  three  to  five  days.  Should 
there  be  doubt  as  to  whether  a  reaction  occurred,  when  all  has  become  normal 
the  dose  last  given  should  be  repeated,  it  being  inadvisable  under  such  cir- 
cumstances to  increase  the  amount  lest  a  severe  reaction  be  produced,  the 
patient  having  been  sensitized  by  the  preceding  injection. 

This  method  of  using  tuberculin  diagnostically  has  been  very  reliable  both 
in  its  positive  and  in  its  negative  findings. 

Von  Pirquet  Reaction. — Two  drops  of  O.T.  are  placed  on  the  arm,  after 
cleansing  with  ether,  and  the  skin  gently  scarified  through  the  drops;  usually 
a  drop  of  sterile  bouillon  is  placed  between  the  drops  of  tuberculin  to  act  as 
a  control,  and  the  skin  beneath  it  similarly  treated.  All  are  allowed  to  dry 
in  the  air.  A  typical  positive  reaction  consists  in  the  production  of  a  hyperaemic 
and  inflammatory  area  from  four  millimetres  to  three  centimetres  in  diameter. 
But  a  single  papule  may  be  present,  or  there  may  be  numerous  papules,  or 
there  may  be  a  markedly  indurated  zone  exuding  serum. 

This  test  merely  indicates  the  presence  of  a  tuberculous  focus  in  the  body, 
but  does  not  direct  attention  to  its  location. 

TUBERCULIN  THERAPY 
The  indications  for  the  use  of  tuberculin  as  a  therapeutic  measure  are: 
Renal  tuberculosis  when  bilateral,  and  when  unilateral  if  the  opposite  kidney 

is  not  functionally  sufficient  to  care  for  the  needs  of  the  body. 

Vesical  and  ureteral  tuberculosis,  after  removal  of  the  primarily  affected 

kidney,  or  when  the  renal  lesion  cannot  be  extirpated,  or  when  the  bladder  is 

the  primary  seat  of  the  infection. 


•90  GENITO-URINARY  SURGERY 

Prostatitis  and  Seminal  Vesiculitis  (tuberculous). 

Epididymitis,  in  the  presence  of  other  more  extensive  tuberculous  lesions  of 
an  irremovable  character. 

The  preparations  usually  used  are  Bacillen  Emulsion  ("B.  E."),  a  suspen- 
sion of  a  finely -pulverized  virulent  culture  of  tubercle  bacilli,  and  Tuberculin 
Riickstand  ("T.  R."),  an  extract  of  a  dried  pulverized  virulent  culture.  Tuber- 
culinum  Purum  ("T.  P."),  a  purified  Old  Tuberculin,  is  sometimes  used  on 
account  of  its  nontoxic  character,  and  the  speed  with  which  the  dosage  can 
be  increased. 

B.  E.  and  T.  R.  are  given  in  initial  doses  of  0.0001  to  0.001  miHigramme. 
These  doses  are  doubled  at  intervals  of  three  to  five  days,  later  at  intervals 
of  a  week  to  ten  days,  provided  no  reaction  is  excited.  Should  the  slightest 
reaction  occur  the  treatment  must  be  suspended  till  two  or  three  weeks  have 
passed  after  the  reaction  has  subsided,  after  which  the  injections  may  be  recom- 
menced, but  in  doses  one-hundredth  or  one-thousandth  of  that  which  caused 
the  disturbance. 

After  a  large  dosage  has  been  attained,  usually  as  a  result  of  six  months' 
to  a  year's  treatment,  it  is  well  to  discontinue  the  injections  for  a  time,  resuming 
them  if  they  seem  again  necessary. 

Tuberculin  treatment  is  contra-indicated  in  the  presence  of  a  considerable 
degree  of  fever  and  in  markedly  asthenic  patients;  also  in  general  miliary 
tuberculosis.  During  the  treatment  the  patient  must  be  carefully  observed  as 
to  febrile  reaction,  general  health,  and  body  weight,  as  well  as  to  the  effect 
upon  the  local  condition. 

SERA 

Specific  sera  are  produced  by  immunizing  certain  of  the  lower  animals, 
usually  the  horse,  either  to  bacterial  toxins  or  to  the  bacteria  themselves.  The 
immunity  produced  by  their  injection  into  patients  is  of  the  passive  type,  and 
is  transitory  in  its  action.  Sera  are  particularly  useful  in  the  acute  stages  of 
infections. 

The  only  specific  serum  used  specially  in  genito-urinary  surgery  is  that 
prepared  against  the  gonococcus.  Rogers  and  Torrey,  the  originators  of  this 
serum,  first  employed  rabbits  for  its  production.  Rams  and  horses  have  since 
been  used,  their  serum  being  less  likely  to  produce  anaphylactic  phenomena. 
The  dose  has  been  increased  from  the  2  c.c.  originally  recommended  till  at 
present  from  5  to  100  c.c.  are  commonly  administered,  the  dose  being  repeated 
daily  or  less  often  as  indicated.  The  virtue  of  the  serum  lies  in  its  contained 
immune  bodies,  particularly  bacteriolysins. 

The  acute  metastatic  gonorrhoeal  affections,  arthritis,  endocarditis,  etc.,  are 
the  lesions  in  which  antigonococcic  serum  is  most  useful.  It  has  also  seemed 
at  times  to  be  helpful  in  acute  epididymitis,  but  not  in  urethritis  or  prostatitis. 
The  injections  may  be  made  into  any  convenient  part;  the  abdominal^  wall 
and  back  are  usually  selected  for  the  larger  quantities. 

NORMAL    SERUM 
For  the  control  of  hemorrhage,  as  from  the  bladder  or  kidney,  the  subcutane- 
ous or  intravenous  injection  of  normal  serum,  equine  or  human,  is  more  potent 
than  any  other  agent.     The  serum  should  be  given  freely,  20  c.c.  being  the 
minimal  and  100  c.c.  the  maximal  dose,  repeated  according  to  indications. 


CHAPTER  VIII 

SURGERY  OF  THE  PENIS 

ANATOMY  OF  THE  PENIS 

The  penis  in  size  bears  less  constant  relation  to  general  physical  development 
than  does  any  other  organ  of  the  body.  Its  average  length  is  about  three  inches 
when  in  the  flaccid  condition  and  twice  that  when  erect;  its  circumference 
when  it  is  flaccid  averages  about  three  inches.  It  is  made  up  in  the  main  of 
erectile  tissue.  This  is  separated  into  three  distinct  compartments  by  invest- 
ments of  tough  fibrous  tissue.  (See  Fig.  48.)  The  bulk  of  the  penis  is  formed 
by  the  two  corpora  cavernosa  lying  side  by  side  and  capped  by  the  glans,  which 
is  a  continuation  of  the  corpus  spongiosum.  The  corpus  spongiosum,  much 
smaller  in  circumference  than  either  of  the  cavernous  bodies,  lies  in  the  angle 
formed  by  their  apposition,  bearing  to  them  the  relation  that  a  ramrod  does  to 
the  double  barrel  of  a  gun. 

The  cavernous  bodies  arise  from  the  tuberosity  and  ascending  _amus  of  the 
ischium  on  each  side,  and  pass  upward,  forward,  and  inward  until  they  become 
closely  apposed  to  each  other  beneath  the  pubic  symphysis.  They  are  then 
continued  forward,  each  in  a  fibro-elastic  sheath  (tunica  albuginea),  which  in 
front  does  not  form  a  complete  partition  between  the  two  (septum  pectiniforme). 
They  terminate  in  blunt  extremities,  which  are  capped  by  the  glans  (Fig.  49). 

The'  spongy  body — composed  of  erectile  tissue  and  also  invested  by  a 
iibroelastic  sheath — is  made  up  of  a  central  portion  of  comparatively  small  diam- 
eter, through  which  the  urethra  passes,  with  an  expansion  at  each  end,  the  glans 
penis,  capping  the  cavernous  bodies,  and  the  bulb,  lying  in  the  angle  formed 
by  the  two  convergent  crura  of  the  cavernous  bodies,  and  attached  to  the  lower 
surface  of  the  triangular  ligament.  The  flange-like  expansion  at  the  base  of 
the  glans  is  termed'  the  corona,  and  the  depression  behind  this  is  called  the 
cervix,  or  coronary  sulcus. 

In  addition  to  the  tough  fibroelastic  sheath  with  which  the  spongy  and 
•cavernous  bodies  are  each  supplied,  there  is  a  sheath,  termed  Buck's  fascia,  or 
the  fascia  of  the  penis,  which  binds  these  structures  together.  This  covers  in 
the  two  rounded  extremities  of  the  corpora  cavernosa  and  is  firmly  attached 
to  the  base  of  the  glans  penis.  Passing  backward  as  a  complete  investment  of 
the  body  of  the  penis,  it  is  continuous  with  the  suspensory  ligament  above 
and  with  the  deep  layer  of  the  superficial  fascia  below.  Superficial  to  this 
fascia  lies  an  extremely  loose  layer  of  areolar  tissue  without  fat,  containing  a 
thin  layer  of  muscular  fibres  (dartos). 

The  thin  movable  skin  covering  the  penis  is  usually  continued  forward  till 
it  partly  or  completely  covers  the  glans;  it  is  then  doubled  back  upon  itself,  is 
attached  to  the  cervix,  and  is  continued  forward  over  the  glans  penis  till  it  joins 
the  mucous  membrane  of  the  urinary  meatus.  This  reduplication  is  termed 
the  prepuce,  or  foreskin.    It  passes  forward  as  a  tough  fibrous  band,  called  the 

91 


92 


GENITO-URINARY  SURGERY 


frjenum,  from  the  lower  central  part  of  the  coronary  sulcus  to  just  beneath  the 
urinary  meatus.  At  the  preputial  orifice  the  subcutaneous  layer  is  especially 
well  developed,  often  forming  a  tough  fibrous  ring.  The  inner  surface  of  the 
prepuce  and  the  covering  of  the  glans  penis  are  moist,  thin,  and  more  like  mucous 
membrane  than  like  ordinary  skin.  On  the  flange-like  expansion  of  the  glans, 
particularly  on  its  anterior  aspect,  are  placed  the  glands  of  Tyson,  which  secrete 
a  cheesy  substance,  termed  smegma;  this,  when  it  undergoes  decomposition,  has  a 
characteristic  offensive  odor. 

The  suspensory  ligament  of  the  penis  is  a  strong,  triangular,  flbro-elastic 
band  attached  to  the  front  of  the  pubic  symphysis  and  to  the  two  cavernous 
bodies  at  their  angle  of  junction. 

The  muscles  of  the  penis  are  the  erector  penis  or  ischiocavernosus,  the  accel- 


da  ddv    sdv 


ddv  sdv      sk    da 


Fig.  48. — Cross  sections  of  formalin-hardened  penis  at  different  levels.  A,  through  glans,  near 
tip;  B,  about  middle  of  glans;  C,  through  corona;  D,  body,  distal  part.  E,  body,  proximal  part.  cc, 
corpus  cavernosum;  cs,  corpus  spongiosum;  da,  dorsal  artery;  ddv,  deep  dorsal  vein;  e,  fibrous  envelope; 
eg,  erectile  tissue  of  glans;  f,  frajnum;  ft,  fibrous  tissue;  s,  fibrous  septum;  sdv,  superficial  dorsal  vein; 
sf,  superficial  fascia;  sk,  skin;  ta,  tunica  albuginea;  u,  urethra.     (Deaver.) 

erator  urinse  or  bulbocavernosus,  and  the  unstriped  muscular  fibres  of  the 
erectile  tissues  and  of  the  urethra. 

The  erector  penis  muscles  are  more  concerned  in  exercising  pressure  upon 
veins,  and  thus  increasing  turgescence,  than  in  mechanically  altering  the  posi- 
tion of  the  penis.  They  arise  from  the  ischiatic  tuberosities  and  are  inserted 
in  the  lower  side  of  the  fibrous  sheath  of  the  corpora  cavernosa. 

The  bulbocavernosi  arise  from  the  central  perineal  point,  and,  passing  up- 
ward and  forward,  encircle  the  bulb  and  posterior  part  of  the  spongv  body. 
The  action  of  these  muscles  is  to  expel  by  their  contraction  the  last  drops  of 
urine  and  to  drive  forward  with  force  the  semen  when  it  passes  from  the  posterior 
urethra. 


SURGERY  OF  THE  PENIS 


93 


The  dorsal  arteries  of  the  penis,  two  in  number,  run  forward  through  the 
suspensory  Hgament  on  each  side  of  the  dorsal  vein  to  the  glans  and  prepuce, 
also  giving  branches  to  the  cavernous  bodies.  The  arteries  of  the  corpora 
cavernosa  give  the  main  blood  supply  to  the  erectile  tissue  of  the  cavernous 
bodies.  The  artery  of  the  bulb  gives  the  main  blood  supply  to  the  corpus 
spongiosum.  All  these  vessels  are  derived  from  the  internal  pudic.  In  addi- 
tion, there  is  a  collateral  supply  due  to  an  anastomosis  of  the  same  vessels  with 
branches  of  the  external  pudic. 

The  dorsal  vein  of  the  penis  is  the  largest  efferent  vessel  of  this  organ; 


Urethral   mucosa   of 
fossa    navicularis 


Corpus  spongiosum 


Superficial     fascia 
or    dartos 


Corpus  spongiosum 


\      of   glans 


Septum  pectiniforme 


uck's  fascia  or 
fascia  of  the  penis 


Fig.   49. — Structure  of  the  penis. 

it  passes  backward  in  a  groove  on  the  dorsum  of  the  penis  through  the  sus- 
pensory ligament  and  into  the  prostatic  plexus;  the  smaller  veins  nearly  all 
pass  backward,  pouring  their  blood  into  the  same  plexus. 

The  nerves  of  the  penis  are  derived  from  the  internal  pudic  (the  dorsal 
nerve  of  the  penis)  and  from  the  hypogastric  plexus  (nervi  erigentes  to  the 
erectile  tissue). 

The  lymphatics  pass  partly  to  the  inguinal  region,  particularly  those  of 
the  glans,  the  foreskin,  the  surface  of  the  penis,  and  the  anterior  part  of  the 
urethra,  partly  to  the  deep  pelvic  lymphatic  system. 

The  tensile  strength  of  the  penis,  because  of  its  tough  fibrous  investments, 
is  sufficient  to  bear  the  entire  weight  of  the  body.  The  fibrous  investment  of 
the  blunt  extremities  of  the  two  cavernous  bodies  where  they  are  capped  by 


94  GENITO-URINARY  SURGERY 

the  glans  delays,  and  sometimes  prevents,  the  backward  extension  of  inflam- 
matory or  infiltrating  processes,  particularly  cancerous  infiltration,  which  pri- 
marily involve  the  glans.  This  fibrous  sheath,  being  a  continuation  of  the  deep 
layer  of  the  superficial  fascia,  also  limits  the  forward  extension  of  urinary 
and  purulent  infiltrations  beneath  this  fascia,  such  infiltrations  sparing  the 
glans. 

The  free  blood  supply  of  the  penis  and  the  rich  innervation  of  the  organ 
insure  rapid  healing  in  case  of  wounds,  and  justify  conservative  treatment  even 
though  it  has  been  .nearly  severed  or  extensively  crushed. 

The  lymphatic  vessels,  passing  as  they  do  to  both  the  inguinal  and  pelvic 
nodes,  carry  infection  in  both  directions.  In  case  of  malignant  disease  with 
involvement  of  the  nodes  of  the  groin,  removal  of  the  disease  together  with  these 
nodes,  though  it  gives  no  assurance  against  deep  recurrence,  is  indicated,  since 
the  inguinal  is  often  an  earlier  involvement  than  the  pelvic. 

The  lax  vascular  subcutaneous  tissue  readily  becomes  (Edematous  either 
from  local  or  from  general  causes,  especially  in  the  region  of  the  foreskin. 

The  delicate,  richly  innervated  skin  is  extremely  sensitive  to  irritants. 

ANOMALIES  OF  THE  PENIS 

These  are  rarely  observed  unassociated  with  other  malformations.  The  penis 
may  be  absent,  concealed,  minute,  gigantic,  double,  twisted,  or  adherent.  A 
large  percentage  of  those  thus  afflicted  are  mentally  deficient. 

Absence  of  the  Penis. — Of  this  anomaly,  unassociated  with  other  deformi- 
ties, nine  cases  have  been  reported.  In  one  case  the  urethra  opened  into  the 
perineum,  in  the  others  just  within  the  anal  sphincter.  Demar quay's  patient 
had  reached  the  age  of  twenty-seven  when  he  developed  an  acute  orchitis. 
The  urethra  opened  into  the  anus,  just  anterior  to  which  was  a  small,  wart-like 
projection  of  erectile  tissue.  Venereal  excitement  caused  this  tissue  to  become 
turgid,  and,  if  sufficiently  prolonged,  was  followed  by  escape  of  semen  through 
the  urethra.  The  small  bifid  scrotum  simulates  the  conformation  of  the  female, 
the  deformity  constituting  male  pseudohermaphroditism  (see  p.  96).  Harris 
notes  that  the  sex  can  be  determined  by  observing  the  nature  of  the  upper 
margin  of  the  pubic  hair,  this  being  a  straight  transverse  line  in  the  female, 
while  in  the  male  it  extends  upward  near  the  median  line. 

Concealed  Penis. — Absence  of  the  penis  may  be  seeming  only,  the  organ 
being  concealed  beneath  the  surface.  In  one  such  case  an  incision  freed  the 
organ  and  enabled  the  infant,  who  was  suffering  from  retention  of  urine,  to 
pass  his  water. 

Treatment  of  the  malformation  is  usually  unnecessary  on  account  of  the 
relative  greater  severity  of  concomitant  deformities.  When,  however,  there  is 
a  chance  for  survival,  opportunity  should  be  taken  to  search  thoroughly  for  a 
concealed  rudimentary  penis.  This,  if  found,  should  be  dissected  free  and, 
by  plastic  operation,  covered  with  integument  derived  from  the  surrounding 
parts. 

Micropenis. — Arrested  growth  of  an  otherwise  perfectly  formed  penis  is 
by  no  means  uncommon,  though  this  rarely  produces  results  so  marked  that 
the  condition  may  be  termed  anomalous.    A  flaccid  adult  penis  less  than  two 


SURGERY  OF  THE  PENIS 


95 


inches  in  circumference  and  two  and  a  half  inches  in  length  is  abnormal,  though 
even  in  such  a  case  the  erectile  tissue  may  be  dilatable  to  an  unusual  degree, 
thus  making  the  organ  normal  in  size  when  in  a  condition  of  physiological  activ- 
ity. In  some  reported  cases  the  penis  has  varied  in  size  from  that  of  a  quill 
to  that  of  the  last  two  joints  of  the  little  finger. 

As  seen  in  adults,  stunting  of  the 
penis  is  perhaps  more  commonly  due 
to  excessive  masturbation  or  to  other 
causes  interfering  with  development 
than  to  congenital  defect. 

Treatment. — A  minute  penis  when 
observed  at  birth  or  shortly  after  does 
not  require  treatment,  except  for  the 
relief  of  preputial  adhesions  or  of  tight 
phimosis,  since  the  organ,  as  is  the  case 
with  the  testicles,  may  before  puberty, 
or  about  this  time,  grow  rapidly  and  at- 
tain normal  dimensions.  A  tight  fore- 
skin should  be  removed,  and  any  abnor- 
mal condition  interfering  with  local 
growth  should  be  remedied. 

When  the  condition  is  observed  soon 
after  puberty,  or  in  the  young  adult, 
the  prospect  for, ultimate  growth  is  by 
no  means  hopeless.  In  these  cases 
physiological  activity  of  the  part  is  at 
times  followed  by  a  rapid  growth  till 
normal  size  is  reached. 

For  the  purpose  of  developing  a 
stunted  penis  a  suction  apparatus  has 
been  employed.  The  penis  is  slipped 
into  a  large  cylinder  fitting  closely 
around  the  root  of  the  organ;  from  this 
cylinder  the  air  is  partly  exhausted  by 
means  of  a  rubber  bulb.  This  causes 
congestion,  distention  of  the  erectile  tissue,  and,  it  is  asserted,  permanent  en- 
largement.    Such  a  treatment  to  be  efficient  would  have  to  be  long  continued. 

Megalopenis. — In  congenital  imbeciles  the  penis  is  often  of  unusual  size,, 
and  in  dwarfs  and  hunchbacks  it  is  not  uncommonly  developed  not  only  out 
of  proportion  to  the  other  parts  of  the  organism,  but  even  beyond  the  average 
for  individuals  of  normal  growth;  this  is  also  noted  in  precocious  puberty 
(Fig.  50). 

Hypertrophy  of  the  penis  may  be  a  source  of  danger,  since  an  excessive 
development  predisposes  to  abrasions  and  fissures  through  which  inoculation 
with  venereal  diseases  may  occur. 

Double  Penis. — A  few  authentic  cases  illustrative  of  this  anomaly  have 
been  reported.  The  two  organs  are  usually  placed  side  by  side,  and  there  are 
other  evidences  of  monstrosity  by  fusion.     In  at  least  two  reported  cases  each. 


Fig.     50. — Precocious    sexual    development. 
(From    Mutter   Museum,    College  of    Physicians, 
Philadelphia,    Pa.) 


96 


GEXITO-URIXARY  SURGERY 


organ  was  functionally  perfect  (Fig.  51).  In  partial  division  of  the  penis 
but  one  portion  of  the  organ  may  be  traversed  by  an  urethra;  division  of  the 
urethra  is  never  carried  farther  back  than  the  prostatic  region.  Olsner's  case 
urinated  from  one  penis  and  ejaculated  semen  from  the  other. 

Torsion  of  the  penis,  or  a  twisting  of  the  organ  on  its  long  axis  so  that 
the  frsenum  looks  forward,  is  extremely  rare,  unless  hypospadia  or  other  mal- 
formation is  present.  Urination  and  ejaculation  of  the  semen  are  not  mate- 
rially interfered  with;  hence  treatment  would  be  indicated  only  from  a  cosmetic 
standpoint. 

Adherent  Penis. — Rarety,  as  an  isolated  anomaly,  the  penis  is  found  ad- 
herent to  the  scrotum  through  nearly  its  whole  extent.  This  materially  inter- 
feres with  function,  and  should  be  remedied  by  freeing  the  organ,  so  cutting 
flaps  that  the  raw  surface  may  be  covered. 


Fig.  51. — Double  penis. 

Hermaphroditism  implies  the  possession  of  both  testicles  and  ovaries.  The 
deformity  is  so  rare  that  its  ver\^  existence  has  been  denied.  Auto-impregnation 
has  never  been  observed. 

Pseudohermaphroditism,  in  which  an  individual  of  one  sex  simulates  in  genital 
conformation  that  of  the  other,  is  a  relatively  common  condition.  In  males  the 
penis  is  atrophic,  the  scrotum  bifid,  there  is  perineal  hypospadias,  and  the  tes- 
ticles are  undescended;  females  exhibit  hypertrophy  of  the  clitoris  (Fig.  52) 
and  absence  of  vagina,  or  great  reduction  of  the  size  of  this  canal,  while  the 
uterus  and  ovaries  may  be  so  small  that  their  palpation  per  rectum  is  difficult 
or  impossible.  The  determination  of  sex  must  in  part  be  based  on  the  nature 
of  the  genital  organs,  and  in  part  on  extragenital  sexual  characteristics,  as  the 
general  conformation  of  the  body,  distribution  of  hair,  development  of  the 
breasts,  and  tone  of  the  voice;  but  simulation  of  the  opposite  sex  often  extends 
even  to  these. 


SURGERY  OF  THE  PENIS 


97 


Treatment  of  this  condition  is  indicated  only  for  cosmetic  purposes,  or  for 
making  sexual  approach  possible. 

ANOMALIES   OF   THE   PREPUCE 

The  foreskin  may  be  absent,  in- 
completely developed,  redundant,  or 
adherent  to  the  glans;  the  preputial 
orifice  may  be  absent  or  extremely 
small;  the  fraenum  may  be  abnormally 
short. 

Absence  or  incomplete  development 
requires  no  treatment,  nor  does  redun- 
dancy urgently  demand  surgical  inter- 
vention, except  where  it  is  complicated 
with  phimosis  and  an  irritated  or  in- 
flammatory condition  of  the  glans. 

Adhesions  between  the  glans  and 
the  inner  surface  of  the  prepuce  are 
present  in  many  infants.  They  may 
be  the  result  of  a  balanoposthitis,  but 
are  usually  congenital  and  associated 
with  phimosis. 

Adhesions  may  appear  in  the  form 
of  comparatively  narrow  bridles  or 
bands,  or  may  involve  broad  areas. 
Commonly  the  symphysis  is  limited  to 
the  corona,  and  is  so  tight  that  in  the 
operation  for  circumcision  the  line  of 
adhesion  is  frequently  taken  for  the 
normal  line  along  which  the  mucous 
membrane  is  reflected  behind  the  glans, 
and  thus  the  coronary  sulcus  is  not 
freed  of  the  retained  smegma  so  habitu- 
ally found  here  in  such  cases.  Excep- 
tionally the  whole  surface  of  the  glans  adheres  to  the  foreskin,  the  lips  of  the 
meatus  alone  being  free.  Adhesions  between  the  foreskin  and  the  glans  exception- 
ally act  as  sources  of  reflex  irritation,  causing  nervous  phenomena  of  a  convulsive 
or  paralytic  type.  Children  in  whom  the  adhesions  are  tightest  and  most  extensive 
commonly  exhibit  a  penis  below  the  average  size.  In  the  adult  such  adhesions,  at 
least  as  congenital  deformities,  are  rare,  since  the  bond  of  union  is  easily  torn  by 
slight  mechanical  interference.  Occasionally  the  bands  are  so-  tough  that  nothing 
short  of  section  can  free  them. 

The  treatment  of  adhesions  between  the  glans  and  the  foreskin  is  in  ordinary 

cases  readily  carried  out.     Phimosis  having  been  relieved,  either  by  stretching 

the  preputial  orifice  or  by  circumcision,  stripping  back  should  be  practised  till 

the  coronary  sulcus  is  freed  through  its  whole  extent,  usually  exposing  a  ring 

■7  . 


Fig.  52. — Hypertrophy  of  the  clitoris.  Ovaries 
in  the  labia  majora  between  which  is  the  vaginal 
opening.  (From  Mutter  Museum,  College  of 
Physicians,    Philadelphia.) 


98  GEXITO-URIXARY  SURGERY 

of  smegma.  Daily  retraction,  washing,  and  the  application  of  a  bland  ointment 
should  be  continued  till  the  inflammation  resulting  from  the  stripping  has 
subsided. 

Obliteration  or  occlusion  of  the  preputial  orifice  may  not  be  detected  directly 
after  birth,  but  cannot  long  escape  attention,  because  of  failure  to  pass  water 
and  the  formation  of  a  tumor  at  the  end  of  the  penis,  due  to  distention  of  the 
preputial  sac  -^ith  urine.  Demarquay,  however,  reports  a  case  of  four  months' 
standing  with  a  prepuce  distended  to  the  size  of  a  bladder. 

The  treatment  is  circumcision. 

Narrowing  of  the  Preputial  Orifice — Phimosis 

The  term  phimosis  implies  that  the  preputial  orifice  is  too  small  to  allow 
retraction  of  the  foreskin  behind  the  glans.  The  opening  may  be  so  small  that 
a  probe  will  pass  "^^ith  difficult3^    Phimosis  may  be  congenital  or  acquired. 

Congenital  Phimosis. — This  condition,  present  in  the  great  majority  of 
male  infants  at  birth,  usually  causes  no  symptoms,  and  spontaneously  dis- 
appears at  about  the  age  of  seven.  Exceptionally  the  narrowed  orifice  is  a  cause 
of  continued  or  recurring  inflammation,  characterized  by  balano-posthitis,  warts, 
fissures,  and  ultimately  adhesions,  or  by  obstruction  to  the  free  flow  of  urine, 
resulting  in  not  merely  local  inflammation  and  exceptionally  preputial  calculi, 
but  giving  rise  to  vesical  irritabiUty  and  its  attendant  consequences.  Moreover, 
certain  reflexes  have  been  attributed  to  phimosis,  among  which  may  be  named 
retention  or  incontinence  of  urine,  arrested  development  of  the  penis,  precocious 
sexualism,  seminal  weakness,  spastic  palsies,  simulated  hip-joint  disease,  muscular 
incoordination,  convulsions,  colic,  indigestion,  night  terrors,  ^\^len  there  are 
distinct  e\ddences  of  local  irritation  associated  with  symptoms  of  general  nerve 
disturbance,  the  possibility  of  a  relation  between  the  latter  and  the  phimosis 
must  be  carefulh'  weighed. 

Acquired  Phimosis,  when  permanent  {i.e.,  cicatricial),  differs  from  the  con- 
genital form  in  that  the  redundant  skin  lying  in  front  of  the  preputial  orifice  is 
usuafly  wanting,  and  the  margins  of  the  latter  are  felt  as  a  more  or  less  irregularly 
indurated  band  or  circle,  which  instead  of  rolling  back  on  attempts  at  retraction 
slowly  stretch,  tightly  embracing  the  glans. 

\Mien  temporar}^,  acquired  phimosis  is  due  to  swelling,  usually  inflammatory 
or  congestive. 

Treatment. — Permanent  phimosis,  whether  congenital  or  acquired,  should  be 
treated  by  operation  whenever  it  is  responsible  for  local  or  reflex  symptoms.  As 
a  prophylactic  against  gonorrhoea,  chancroid,  chancre,  and  cancer,  the  operation 
is  desirable,  even  when  the  condition  excites  no  trouble. 

The  treatment  of  temporary  phimosis  due  to  inflammatory  swefling  will  be 
described  when  considering  the  various  affections  which  may  produce  this  con- 
dition. 

The  operation  of  choice  is  circumcision. 

Stripping  back  is  applicable  only  in  the  congenital  form  of  phimosis.  It  is 
accomplished  by  pressing  the  skin  of  the  penis  back  toward  its  root  with  the 
tips  of  the  middle  and  ring  fingers,  which  are  then  used  to  steady  the  organ  while 
the  foreskin  is  manipulated  with  the  index-fingers  and  thumbs.    The  manipu- 


SURGERY  OF  THE  PENIS  99 

lations  consist  in  pressing  back  the  skin  firmly  till  the  glans  emerges  through 
the  preputial  opening.  Adhesions  may  be  broken  up  with  a  probe  or  finger- 
nail, or  more  easily  by  grasping  the  glans,  as  soon  as  sufficiency  of  it  is  exposed, 
with  the  thumb  and  forefinger  covered  with  a  single  layer  of  gauze,  catching 
the  prepuce  in  a  similar  manner,  and  tearing  one  from  the  other.  It  is  of  the 
utmost  importance  that  the  whole  of  the  glans  be  freed.  The  raw  surfaces  are 
then  washed  with  weak  bichloride  solution  (1  to  6000),  dried,  well  greased 
with  boric  ointment,  or  olive  oil,  and  the  foreskin  drawn  forward.  The  foreskin 
must  be  retracted  for  washing  and  dressing  daily  for  ten  to  fourteen  days,  prefer- 
ably by  the  physician. 

Circumcision 

This  operation  is  indicated  in  every  case  of  phimosis  in  children.  In  the 
absence  of  phimosis  circumcision  is  also  indicated  where  there  is  a  tendency 
to  the  formation  of  venereal  warts,  or  to  prolonged  attacks  of  balanoposthitis,  to 
recurrent  herpes  progenitalis,  to  fissurings  and  erosions  during  intercourse,  to 
hypersecretion  on  the  part  of  Tyson's  glands,  to  sexual  erethism  without  evident 
cause,  to  apparently  causeless  functional  disturbances  of  the  bladder,  such  as 
nocturnal  enuresis,  and  to  masturbation. 

In  preparing  for  operation  the  parts  are  thoroughly  washed  with  hot  soap- 
suds, the  preputial  sac  being  cleaned  by  means  of  injections  of  I  to  40  carbolic 
in  1  to  4000  sublimate  solution.  The  ordinary  antiseptic  precautions  are 
observed.  The  penis  is  passed  through  a  small  opening  made  in  the  centre  of  a 
sterilized  towel,  and  the  latter  is  then  spread  out,  thus  preventing  the  wound 
surface  from  coming  in  contact  with  the  skin, 

A  general  anaesthetic  should  be  given  to  boys  less  than  twelve  years  of  age; 
older  children,  when  not  of  an  unusually  nervous  disposition,  and  adults  can 
be  operated  upon  painlessly  under  a  local  anaesthetic.  For  the  induction  of 
anaesthesia  half  an  ounce  of  0.25  per  cent,  solution  of  novocaine  in  half-normal 
saline,  to  which  have  been  added  one  or  two  drops  of  suprarenalin  solution  ( 1 
to  1000),  should  be  sterilized  by  boiling.  The  solution  must  be  prepared  imme- 
diately before  use.  The  nerves  to  the  outer  layer  of  the  prepuce  may  be  blocked 
by  injecting  20  to  30  minims  of  the  solution  beneath  the  skin  at  three  equidistant 
points  about  the  base  of  the  penis  (Fig,  53).  The  nerves  to  the  inner  layer 
of  the  prepuce  may  be  caught  either  by  an  intradermal  infiltration  as  close  to 
the  corona  as  the  needle  can  be  inserted  (applicable  to  cases  in  which  retraction 
is  possible),  or  by  injecting  from  30  to  60  minims  into  the  inner,  upper  quadrant 
of  each  corpus  cavernosum;  anaesthesia  by  this  method  is  not  invariably  perfect 
in  the  region  of  the  fraenum,  and  the  passage  of  the  needle  through  the  tunica 
albuginea  causes  some  pain  in  most  cases,  so  that  when  applicable  the  former 
method  is  the  one  of  choice.  Five  to  fifteen  minutes  are  required  for  the  novo- 
caine to  take  effect;  anaesthesia  lasts  forty-five  to  sixty  minutes. 

The  operation  is  begun  by  marking  the  skin  as  it  lies  without  traction  over 
the  bulge  of  the  corona  and  the  notch  of  the  fraenal  attachment  to  the  glans  by 
nicking  it  with  scissors;  if  phimosis  forceps  are  not  to  be  used,  additional  nicks 
should  be  made,  one  on  each  side,  midway  between  the  first  marks.  The  prepuce 
is  now  retracted,  the  orifice  being  cut  if  this  be  necessary  to  secure  exposure 


100 


GENITO-URINARY  SURGERY 


of  the  glans,  adhesions  to  the  latter  are  separated,  and  the  coronary  sulcus, 
containing  in  infants  dry,  cheesy  matter,  is  fully  exposed  and  thoroughly  cleansed. 
The  foreskin  is  then  drawn  forward  and  is  split  dorsally  and  cut  away  to  either 
side  along  the  line  indicated  by  the  nicks,  using  these  alone  as  a  guide,  or 
amputated  through  the  slot  of  a  phimosis  forceps  applied  in  the  direction  indi- 
cated, from  above  downward  and  forward,  the  skin  being  drawn  forward  and  the 
glans  pushed  back  as  the  forceps  are  tightened.  There  will  be  left,  if  phimosis 
forceps  have  been  used,  the  inner  layer  of  the  foreskin,  and  often  the  preputial 
orifice  with  a  ring  of  true  skin  about  it.  The  inner  layer  is  next  removed  by 
slitting  it  dorsally  with  scissors  to  within  one-sixth  of  an  inch  of  its  attachment 
to  the  corona,  and  then  trimming  off  each  side,  leaving  that  width  of  the  inner 


Fig.  53. — Blocking  superficial  ner\'es  of  penis. 

layer.  Bleeding  must  be  completely  stopped  by  twisting  the  vessels  or  by 
tying  them  with  fine  catgut. 

Suturing  is  done  with  No.  0  plain  sterile  catgut,  the  first  suture  being  of 
the  mattress  variety  and  placed  at  the  frsenum  so  as  to  make  a  neat  approxima- 
tion at  this  point.  Accurate  apposition  is  secured  by  inserting  from  two  to  four 
continuous  sutures,  according  to  the  size  of  the  penis,  the  first  stitch  of  each 
being  inserted  before  any  of  them  are  completed  (the  order  of  insertion  in  a 
four-suture  operation  being  ventral,  dorsal,  right  lateral,  left  lateral). 

For  the  juvenile  and  adult  a  narrow  bandage  of  dr}^  sterile  gauze  is  applied 
about  the  line  of  suture  with  sufficient  firmness  to  insure  against  oozing.  In 
clean  cases  this  dressing  need  not  be  changed  for  two  to  five  days  unless  it  should 
become  dirty  or  too  tight.  Prolonged  soaking  in  a  dilute  antiseptic  solution, 
supplemented  by  a  peroxide  spray,  facilitates  its  removal.  Infants  are  dressed 
with  sterile  gauze  thickly  smeared  with  boric  ointment,  held  in  place  by  the  diaper 
and  changed  as  frequently. 


SURGERY  OF  THE  PENIS  101 

CEdematotis  swelling  coming  on  after  the  operation  is  completed  or  even 
during  its  course  is  commonly  due  to  the  use  of  irritant  antiseptics,  though  it 
may  occur  without  assignable  cause.  It  subsides,  in  part  at  least,  in  from  one 
to  two  days  under  elevation,  the  appUcation  of  evaporating  lotions  (dilute  alcohol 
and  lead  water  equal  parts) ,  and  the  administration  of  a  brisk  purgative.  It  may 
persist  for  months  in  the  form  of  a  semi-sohd  oedema  about  the  frsenum.  Its 
disappearance  is  hastened  by  stimulating  and  absorbent  ointments,  such  as 
thyol  or  ichthyol  ten  parts,  and  lanolin  ninety  parts. 

Injection  calls  for  the  removal  of  sufficient  sutures  to  give  adequate  drainage, 
elevation  of  the  part,  and  the-  application  of  dressings  kept  wet  with  dilute 
alcohol  and  water  equal  parts  and  frequently  changed. 

Interference  with  Erection. — This  results  from  the  removal  of  too  much 
skin,  and  is  to  be  avoided  by  carefully  marking  the  skin  before  applying  the 
clamp.  Owing  to  the  great  extensibility  of  the  skin,  the  ultimat-e  prognosis  is 
good;  at  times  the  fraenum  will  require  division. 

Recurrence  of  the  Phimosis. — When  too  much  of  the  mucous  layer  of  the 
foreskin  has  been  left,  phimosis  may  recur  in  a  more  severe  form .  than  that 
for  which  the  original  operation  was  undertaken,  the  cicatricial  tissue  along  the 
line  of  suturing  sometimes  contracting  very  rapidly.  A  strip  of  mucous  mem- 
brane wider  than  a  fourth  of  an  inch  should  never  be  left.  If  narrower  than  a 
sixth  of  an  inch,  it  is  somewhat  difficult  to  insert  the  sutures  satisfactorily. 

Paraphimosis. 

When  the  prepuce  has  been  retracted  behind  the  glans  and  cannot  again  be 
brought  forward,  the  condition  is  termed  paraphimosis.  The  exciting  cause  is 
usually  a  more  or  less  forcible  retraction  of  a  tight  foreskin,  though  occasionally 
inflammatory  swelling  will  cause  the  foreskin  to  roll  back. 

In  gonorrhoea,  chancroid,  chancre,  balanoposthitis,  and  all  lesions  of  the 
genitalia  attended  by  sv/elling  of  the  foreskin,  this  complication  is  particularly 
liable  to  occur.  It  is  most  frequently  observed  in  children  as  a  result  of  manipu- 
lation of  the  parts. 

When  a  narrow  preputial  orifice  is  drawn  behind  the  corona  the  constriction 
it  exerts  upon  the  parts  causes  .rapid  swelling.  The  glans  becomes  enlarged 
and  glossy.  It  is  often  partially  concealed  by  a  thick  collar  of  shiny,  oedematous 
mucous  membrane,  behind  which  there  is  a  deep,  excoriated  sulcus,  and  back 
of  this  sulcus  there  is  usually  a  second  oedematous  band  less  marked  than  the 
one  lying  immediately  behind  the  coronary  sulcus.  The  penis  seems  to  have 
a  distinct  upward  kink  or  bend  just  behind  the  glans,  this  appearance  being  due 
to  the  deep  notch  caused  by  the  margin  of  the  retroverted  preputial  orifice  of  the 
penis,  and  to  the  oedematous  swelling  which  is  particularly  marked  about  the 
position  of  the  fraenum.  In  some  cases,  where  the  tense,  inelastic  edge  of  the 
orifice  exerts  a  more  than  usual  amount  of  constriction,  circulation  is  markedly 
interfered  with,  and  ulceration  and  even  sloughing  involving  both  the  foreskin' 
and  the  head  of  the  penis  may  take  place. 

When  the  swelHng  consequent  upon  paraphimosis  is  well  developed  (Fig.  54) 
there  is  encountered  first  a  furrow  (a),  the  coronary  sulcus,  which  is  normally 
found  behind  the  corona;  in  these  cases  it  appears  deeper  because  it  is  intensified 
by  the  oedematous  swelling.     Covering  this  furrow,  and  even  overlapping  the 


102 


GENITO-URINARY  SURGERY 


glans  somewhat,  is  a  shiny,  oedematous  collar  of  mucous  membrane  (6).  This 
is  that  portion  of  the  prepuce  which  is  normally  in  contact  with  the  posterior 
face  and  border  of  the  corona.  Behind-  this  swollen  fold  is  found  a  second  deep, 
often  ulcerated  furrow  (c) ;  this  is  the  actual  seat  of  constriction,  and  behind 
it  is  placed  yet  another  ridge  of  swollen  integument  (d). 

Paraphimosis  is  attended  with  very  severe  pain,  which  does  not  intermit 
until  the  constriction  has  been  relieved,  either  by  operation  or  by  the  process  of 
ulceration.    Where  surgical  interference  is  delayed,  or  has  not  been  successful 


Fig.  54. Paraphimosis. 


in  remedying  the  trouble,  the  subsequent  cicatricial  contraction  may  occasion 
great  deformity. 

Treatment. — When  a  paraphimosis  is  due  to  inflammatory  swelHng  and  causes 
no  harmful  constriction,  its  existence  may  be  ignored. 

As  a  general  rule,  however,  paraphimosis  calls  for  reduction  by  either  non- 
operative  or  operative  measures.  The  former  is  accomplished  by  gently  squeezing 
the  glans  between  the  thumbs  and  forefingers  (Fig.  55),  and  drawing  it  out 
rather  than  pressing  it  inward,  while  the  ring  and  middle  fingers  catch  the  skin 
back  of  the  constricting  band  and  endeavor  to  pull  it  forward.  When  this  fails 
the  size  of  the  glans  can  sometimes  be  reduced  by  wrapping  about  it  a  narrow 
strip  of  rubber  dam  in  much  the  same  manner  as  an  Esmarch's  bandage  is 
applied.  When  this  has  been  done  the  handle  of  a  scapel  can  usually  be  inserted 
beneath  the  constriction,  and  from  behind  forward  when  the  foreskin  has  been 
rolled  back,  and  the  constricting  ring  can  thereby  be  levered  forward  over  the 
corona.  The  successful  application  of  these  methods  is  much  facilitated  by 
light  anaesthesia. 

When  nonoperative  measures  fail  or  sloughing  threatens,  reduction  must  be 
accomplished  by  cutting  the  constricting  band,  which,  when  the  foreskin  has 


SURGERY  OF  THE  PENIS 


103 


been  rolled  back,  lies  behind  an  oedematous  collar;  when  the  foreskin  has  been 
stretched  back,  lies  in  the  coronary  sulcus.  A  half-inch  cut  in  the  middorsal  line 
supplies  adequate  section  of  the  constricting  band,  as  indicated  by  easy  and 
complete  reduction.  The  incision  may  be  left  to  heal  by  granulation,  or  it  may 
be  sutured  at  right  angles  to  its  long  axis.  Hot  compresses  are  applicable  to 
cases  of  threatening  or  actual  sloughing. 


Fig.  55. — Reduction  of  paraphimosis. 

Shortness  of  the  Fraenum 

This  congenital  or  acquired  deformity  in  certain  cases  interferes  with  com- 
plete erection  of  the  glans,  turning  the  orifice  of  the  meatus  downward,  and  not 
only  preventing  ejaculation  in  the  proper  direction,  but  also  rendering  sexual 
intercourse  painful,  or  even  impossible.  Treatment  is  by  division  of  the  ivxaum, 
with  suture  of  the  resultant  gaping  wound  at  right  angles  to  its  long  axis. 


INJURIES  OF  THE  PENIS 

Contusion. — This  implies  an  injury  by  crushing  force  without  lesion  of  the 
skin.  Owing  to  the  looseness  of  the  cellular  tissue,  ecchymosis  and  oedema  are 
often  so  pronounced  as  to  simulate  rapid  gangrene. 

When  the  vessels  of  the  cavernous  bodies  are  involved  there  results  a 
circumscribed  fluctuating  tumor,  most  prominent  during  erection.  This  tumor 
is  somewhat  slow  in  forming,  and  occasionally  suppurates.  Under  conservative 
treatment  it  usually  disappears.  When  injury  has  not  only  occasioned  extensive 
extravasation  of  blood,  but  has  lacerated  the  urethral  canal,  the  inflammatory 
phenomena  observed  after  rupture  of  the  urethra  quickly  develop  (see  p.  158). 
Moreover,  there  is  immediately  bleeding  from  the  meatus,  which  should  lead 
to  prompt  diagnosis  and  appropriate  treatment. 

Treatment. — The  treatment  of  contusions  of  the  penis  is  conducted  on  general 
principles — rest,  elevation,  pressure  by  narrow  gauze  bandages,  the  application 
of  evaporating  lotions,  and,  for  the  purpose  of  hastening  absorption,  gentle 
massage. 


104  GENITO-URINARY  SURGERY 

Extensive  swelling  and  discoloration  need  not  occasion  anxiety,  unless  there 
has  been  rupture  of  the  spongy  or  cavernous  bodies  or  of  the  urethra.  When 
gangrene  is  threatened  on  account  of  the  severity  of  the  lesion  or  because  of 
interference  with  circulation  occasioned  by  the  pressure  of  effused  blood,  hot 
antiseptic  fomentations  frequently  repeated  are  indicated.  These  dressings  are 
made  by  wringing  fifteen  or  twenty  layers  of  aseptic  gauze  out  of  a  hot  1  to 
10,000  bichloride  solution.  They  may  be  covered  with  waxed  paper  to  prevent 
evaporation.  If  the  symptoms  are  still  progressive,  free  incision  and  ligation 
of  bleeding  vessels,  followed  by  suture  of  the  wound,  are  indicated.  Emphysema 
is  always  a  serious  symptom,  and  usually  calls  for  free  incision,  with  abundant 
drainage.     It  usually  indicates  a  sloughing  or  gangrenous  process. 

Wounds  of  the  Penis. — These  may  be  incised,  punctured,  lacerated,  con- 
tused, or  a  combination  of  these  forms. 

Incised  Wounds,  if  superficial,  are  readily  closed  and  heal  quickly.  Wounds 
involving  the  erectile  tissue  bleed  freely,  and,  if  transverse  and  extensive,  are 
liable  to  be  followed  by  loss  of  erectile  power  in  the  tissue  lying  anterior  to  the 
wound. 

Treatment. — Hemorrhage  is  checked  by  ligatures:  the  cut  surfaces  are 
apposed  by  sutures  passed  through  the  fibrous  sheath  of  the  erectile  tissue,  but 
no  deeper. 

Inflammatory  reaction  usually  excites  erection,  which  interferes  with  primary 
healing,  and  should  be  prevented  by  full  doses  of  bromide  (oiii  daily),  by  opiupi 
and  belladonna  suppositories,  or  by  hypodermics  of  morphine.  Even  if  the 
penis  hangs  by  but  a  small  strip  of  tissue,  bleeding  points  should  be  hgated 
and  the  fibrous  sheath  should  be  restored  by  suture. 

When  the  penis  is  completely  cut  off,  the  bleeding  vessels  are  tied,  the 
cavernous  bodies  are  covered  in  by  suture  of  their  fibrous  envelopes,  the  skin  is 
drawn  forward  and  sewed  over  the  closed  ends  of  the  corpora  cavernosa,  and 
the  urethra  is  split,  and  secured  to  the  skin  to  prevent  subsequent  stricturing  of 
its  orifice  (see  p.  138). 

When  the  urethra  is  divided  it  should  be  sutured,  and  the  urine  should  be 
drawn  by  a  small,  soft  catheter.  Intermittent  catheterization  is  practised  for 
five  days,  the  instrument  at  each  passing  being  attached  to  a  fountain  syringe 
and  introduced  with  a  stream  of  protargol  (1  to  2000)  flowing  through  it.  After 
the  bladder  is  emptied,  the  fountain  syringe  is  again  attached  to  the  catheter, 
and  as  the  latter  is  withdrawn  the  anterior  urethra  receives  another  antiseptic 
washing.  When  the  introducing  of  the  soft  catheter  is  excessively  painful,  con- 
tinuous catheterization  should  be  practised  (see  p.  73  et  seq.). 

If,  as  a  result  of  cicatrization  following  wounds,  erection  is  complete  but 
there  is  deviation  of  the  penis  from  a  straight  line,  cure  by  operation  may  be 
successful.  When,  however,  there  has  been  obliteration  or  obstruction  of  the 
spaces  of  the  spongy  and  cavernous  bodies,  producing  deviations  and  incomplete 
erections,  treatment  is  unavailing. 

Punctured  Wounds  of  the  penis,  when  inflammatory  symptoms  are  pro- 
nounced and  infection  is  probable,  should  be  converted  into  incised  wounds, 
cleansed,  and  drained  from  the  bottom. 

Contused  and  Lacerated  Wounds  of  the  penis,  under  which  heading  would 


SURGERY  OF  THE  PENIS  105 

come  gunshot  wounds,  are  particularly  dangerous  only  when  the  urethra  is 
involved  or  the  injury  is  so  great  as  extensively  to  devitalize  tissues.  When 
extensive  they  are  liable  to  be  followed  by  imperfect  erection  or  by  distortion 
of  the  penis.  The  treatment  consists  in  subduing  inflammatory  phenomena  and 
providing  for  drainage.  Bleeding  in  these  cases  is  moderate;  when  the  urethra, 
is  involved  permanent  catheterization  is  practised  (see  p.  73). 

Fracture  of  the  Penis. — This  injury,  possible  in  a  literal  sense  only  when 
the  penis  has  undergone  calcification,  occurs  when  during  vigorous  erection  the 
organ  is  subjected  to  a  sudden  twist  or  bend.  The  cause  of  the  injury  is  usually 
a  false  movement  in  coitus,  though  a  wrench  or  a  blow  will  also  produce  it,  as, 
for  instance,  when  the  penis  is  caught  in  closing  a  bureau  drawer,  or  is  bruised 
by  a  falling  window-sash. 

Symptoms. — The  symptoms  of  this  injury  are  sudden,  severe  pain  and  a 
sense  of  something  having  given  way,  consequent  on  a  bending  or  twisting  strain 
of  the  erect  penis.  The  erection  subsides  at  once,  and  there  is  rapid  and 
immediate  swelling. 

Prognosis. — From  the  functional  standpoint  the  prognosis  must  be  guarded. 
When  the  spongy  body  and  urethra  have  been  involved  in  the  injury  extravasa- 
tion of  urine  and  infection  may  occur  (see  p.  160). 

Treatment. — Rest  in  bed,  the  firm  bandaging  of  the  penis  in  the  erect  position 
against  the  abdomen,  the  application  of  evaporating  lotions,  and,  if  needful, 
drawing  the  water  by  catheter  (see  p.  73)  usually  will  be  followed  by  arrest 
of  hemorrhage  and  gradual  absorption  of  clot. 

When  the  blood  effusion  forms  a  large  tumor,  and  particularly  when  the 
hemorrhage  continues,  threatening  by  tension  the  vitality  of  the  part,  an  incision 
must  be  made,  thus  allowing  ligature  of  the  bleeding  vessels  and  accurate  suture 
of  the  torn  fibrous  sheath.  Erections  are  prevented  by  keeping  the  bowels. 
opened  and  by  giving  full  doses  of  potassium  bromide  (3ii  to  oiv  daily) . 

Dislocation  or  the  Penis. — This  accident  is  produced  by  traumatism 
exerted  upon  the  anterior  portion  of  the  flaccid  organ.  The  penis  is  pinched 
out  of  its  sheath  and  driven  into  the  scrotum,  the  loin,  or  the  neighboring 
regions,  much  as  a  grape  is  squeezed  out  of  its  skin.  The  inner  layer  of  the 
prepuce,  which  should  prevent  this  accident,  gives  way  either  at  the  preputial 
orifice  or,  more  commonly,  along  the  line  of  the  coronary  sulcus.  The  urethra 
is  usually  ruptured  in  the  perineal  region. 

Symptoms. — The  symptoms  of  this  accident  are  not  so  marked  as  would  be 
supposed.  The  skin  sheath  of  the  penis  is  often  filled  with  clotted  blood,  thus 
simulating  the  presence  of  a  shrunken  organ.  There  is  usually  free  hemorrhage 
from  the  preputial  orifice.  Later  there  is  extravasation  of  urine,  with  its  con- 
comitant symptoms.  Careful  investigation  will  always  show  the  absence  of  the 
erectile  tissues  from  their  proper  position  and  their  presence  elsewhere. 

Treatment. — The  treatment  consists  in  immediate  replacement  of  the  organ. 
This  usually  requires  an  incision,  though  in  one  reported  case  the  penis  was 
hooked  forward  by  an  instrument  introduced  into  the  preputial  orifice.  There 
should  be  no  hesitation  in  making  the  required  incision  so  free  that  the  proper 
manipulations  for  reduction  can  be  easily  carried  out.  A  perineal  urethrostomy 
may  be  needed  to  care  for  the  urine. 


106  GENITO-URINARY  SURGERY 

INFLAMMATORY  AFFECTIONS  OF  THE  PENIS 

The  penis  and  its  envelopes  are  subject  to  the  inflammations  observed  in 
other  parts  of  the  body.  Aside  from  the  distinctly  venereal  diseases,  eczema, 
dermatitis  (notably  that  from  ivy  poisoning),  pruritus,  urticaria,  erythema, 
intertrigo,  the  bites  of  insects,  parasitic  diseases,  herpes,  erysipelas,  lymphangitis, 
folliculitis,  abscess,  diffuse  cellular  inflammation,  and  gangrene  are  to  be  noted. 

Eczema  very  commonly  affects  both  the  scrotum  and  the  penis,  and  is 
extremely  rebellious  to  treatment.  The  exciting  cause  is  often  chafing  or  rubbing 
of  the  parts,  though  a  constitutional  dyscrasia,  such  as  gout,  diabetes,  or  rheu- 
matism, commonly  predisposes  to  the  disease.  It  usually  appears  on  the  prepuce 
or  about  the  base  of  the  penis. 

The  treatment  is  the  same  as  for  the  disease  situated  in  other  parts  of  the 
body,  except  that,  as  the  skin  is  extremely  sensitive,  irritating  applications 
must  be  avoided. 

Acute  Inflammation  of  the  Penis  may  be  localized  or  diffuse.  It  may 
involve  the  subcutaneous  cellular  tissue  or  the  structure  of  the  erectile  tissue. 
Abscess  is  treated  in  accordance  with  general  principles,  whether  it  be  super- 
ficial or  placed  in  the  substance  of  the  organ,  i.e.,  it  is  opened  and  drained. 

Gangrene  occasionally  results  from  deep-seated  acute  inflammation,  which 
may  be  due  to  local  causes,  such  as  phimosis  or  paraphimosis,  traumatism,  or 
urinary  extravasation,  or  may  develop  as  a  result  of  thrombosis  after  acute 
fever,  such  as  typhoid,  or  may  be  incident  to  diabetes.  The  trophoneurotic 
gangrene  secondary  to  cord  lesions  is  guarded  against  by  dry  cleanliness  and  the 
avoidance  of  pressure. 

Treatment. — The  treatment  of  gangrene  of  the  penis  is  that  applicable  to  this 
condition  in  other  parts  of  the  body.  In  case  the  gangrene  is  rapidly  spreading, 
removal  of  the  dead  tissue  by  scissors  and  curette,  supplemented  by  thorough 
application  of  the  actual  cautery,  is  indicated.  Compresses  soaked  in  hot 
bichloride  solution  (1  to  10,000)  and  changed  every  half-hour  are  applied  till 
healthy  granulations  form,  when  boric  ointment,  or  a  dry  dusting  powder,  such 
as  iodoform,  or  acetanilid,  may  be  substituted. 

When  gangrene  is  less  fulminant  in  type,  hot  compresses,  changed  every 
three  minutes  (bichloride  solution  1  to  10,000,  at  a  temperature  of  110°  F.), 
may  be  applied  for  twenty-four  hours,  supplemented  by  thorough  spraying  of 
the  involved  parts  with  peroxide  solution  every  two  hours.  When  the  gangrene 
is  distinctly  slow  in  type  and  resists  ordinary  treatment,  a  long-continued  general 
bath  or  hip  bath  is  indicated.  This  should  be  kept  comfortably  hot  and  should 
be  mildly  antiseptic  (oSS  bichloride,  or  ^xii  boric  acid,  to  the  bath).  The 
genitalia  should  be  kept  submerged  day  and  night  for  days,  and  even,  in  excep- 
tional cases,  for  weeks.  Many  of  these  cases  of  indolent  gangrene  are  late  mani- 
festations of  tertiary  syphilis  in  persons  afflicted  with  visceral  disease. 

The  systemic  treatment  is  extremely  important  in  all  cases  of  gangrene. 
This  must  be  tonic  and  stimulating.  Easily  digestible  food  in  as  full  quantity 
as  can  be  given,  tonics,  particularly  iron,  strychnine,  and  small  doses  of  bichloride 
(grain  one-sixtieth  thrice  daily),  and  stimulants  are  indicated.     The  bowels 


SURGERY  OF  THE  PENIS 


107 


should  be  moved  regularly.     Diabetic  gangrene  should  receive  appropriate  con- 
stitutional treatment. 

Chronic  Inflammation  of  the  Erectile  Tissues  and  its  fibrous  envelope, 
particularly  of  the  corpora  cavernosa,  results  in  slow,  often  painless,  areas  of 
induration,  which  may  be  fibrous,  calcareous,  or  even  bony  (Fig.  56),  and  which 
attract  attention  only  because  they  prevent  complete  erection.  The  cause  of 
these  indurations  is  unknown.  They  are  observed  in  middle-aged  men,  and  are 
often  associated  with  the  rheumatic  and  gouty  diatheses.  They  have  been, 
regarded  as  late  lesions  of  syphilis.  With  this  disease  they 
have  no  relation,  though  it  must  be  remembered  that  gum- 
mata  may  appear  in  the  corpora  cavernosa. 

Symptoms. — Palpation  demonstrates  one  or  more  circum- 
scribed, hardened,  possibly  tender  areas,  varying  from  the 
size  of  a  split  pea  to  that  of  the  thumb-nail.  The  erect 
penis  is  bent  at  the  seat  of  hardening,  and  often  erection 
is  incomplete  in  the  portion  of  the  involved  cavernous  body 
lying  to  the  distal  side  of  the  lesion. 

Treatment. — The  treatment  of  this  affection  is  without 
avail.  In  the  early  stages,  when  slight  constant  pain  and 
beginning  hardness  indicate  the  nature  of  the  case,  pressure 
by  means  of  a  thin  rubber  bandage,  inunctions  of  mercuric 
ointment,  and  the  internal  administration  of  potassium  iodide 
and  wine  of  colchicum  root,  continued  for  many  months, 
may  prevent  permanent  crippling.  When  the  lesions  are 
fully  formed  the  same  treatment  may  be  tried,  but  with 
slight  prospect  of  success.  When  a  calcareous  or  a  bony 
plate  materially  interferes  with  functional  activity  and  is 
placed  superficially,  there  can  be  no  objection  to  removing 
it  by  a  cutting  operation,  but  the  operator  should  hold  out 
no  definite  hope  of  restoration  of  function. 

Lymphangitis  is  secondary  to  peripheral  inflammation, 
sometimes  nonspecific,  but  usually  of  venereal  origin. 

Symptoms. — The  inflammation  usually  affects  the  lymphatics  of  the  dorsum 
of  the  penis.  Beneath  the  skin  can  be  felt  one  or  more  cords,  often  starting  about 
the  region  of  the  fraenum  and  passing  upward  and  backward  behind  the  corona 
to  the  dorsum  of  the  penis,  along  which  a  distinct  cord  can  be  felt  extending 
as  far  back  as  the  symphysis  pubis.  This  cord  is  tender,  hard,  not  very  sharply 
circumscribed,  and  over  its  course  the  skin  is  reddened  and  sometimes  adherent. 
This  line  of  induration  may  attain  the  size  of  a  lead-pencil.  It  is  attended 
with  a  great  deal  of  pain,  which  is  especially  severe  during  erection.  Exceptionally 
an  indurated  knob  forms,  sometimes  just  behind  the  corona  in  the  loose  sub- 
cutaneous connective  tissue,  sometimes  in  the  course  of  the  dorsal  lymphatics; 
this  slowly  enlarges,  giving  comparatively  little  pain,  softens,  and  on  being 
opened  discharges  pus.  From  this  a  persistent  fistula  may  result  which  can  be 
cured  only  by  extirpation. 

Phlebitis  of  the  dorsal  vein  of  the  penis  would  not  be  accompanied  by  that 
enlargement  of  the  lymphatic  glands  of  the  groin  which  is  rarely  absent  when 


Fig.  56. — Osseous 
growth   of    the    penis. 

(Demarquay.) 


108  GENITO-URINARY  SURGERY 

lymphangitis  of  the  penis  is  observed.  Moreover,  the  vein  passes  backward  in 
the  middle  line,  and  is  not  deflected  towards  the  groins  as  is  the  case  with  the 
lymphatic  vessels,  and  is  placed  more  deeply  so  that  it  cannot  be  lifted  up  with 
the  skin. 

Treatment. — Free  drainage  of  pus  from  the  anterior  urethra,  appropriate 
treatment  directed  towards  lessening  the  severity  of  the  urethritis,  and  careful 
cleansing  of  the  preputial  sac  are  matters  which  should  receive  close  attention. 
Following  these,  rest  should  be  enjoined,  the  bowels  should  be  opened,  and  con- 
tinuous applications  should  be  made  of  cloths  kept  wet  with  alcohol  and  lead 
water  equal  parts.  Hot  baths,  local  or  general,  are  also  serviceable,  and  when  the 
erections  become  troublesome  potassium  bromide  should  be  given  in  sufficient 
doses  to  control  them.  This  drug  failing,  hypodermics  of  morphine  may  be 
given  at  night  to  procure  rest.  WTien  pus  forms  it  should  be  evacuated  by 
incision,  the  remaining  cavity  being  curetted. 

In  a  very  rare  form  of  lymphangitis  the  lymphatic  vessels  of  the  prepuce  are 
dilated  without  marked  inflammatory  phenomena.  The  symptoms  of  this  affec- 
tion usually  appear  after  coitus  or  other  cause  of  acute  congestion.  On  retraction 
of  the  prepuce  the  congested,  semitransparent  lymph-vessels  are  easily  detected, 
passing  upward  and  backward  from  the  frsenum  towards  the  dorsum  of  the 
penis.  The  swelling  subsides  in  a  few  days,  but  recurs  after  each  attempt  at 
coitus,  until  finally  it  becomes  permanent.  When  the  swollen  vessels  are  unduly 
prominent,  mechanical  disturbance  is  followed  by  marked  symptoms  of  local 
inflammation. 

The  treatment  in  the  early  stages  consists  in  prolonged  hot  local  baths  and 
the  use  of  astringents.  Fluidextract  of  hamamelis,  one  part  to  four  parts  of 
water;  ammoniated  mercurial  ointment,  ten  grains  to  the  ounce  of  carbolated 
cosmoline;  ointment  of  belladonna  and  mercury,  one  part  to  four  parts  of 
lanolin,  well  rubbed  in;  or  compresses  kept  wet  in  lead  water  and  laudanum, 
often  effect  cures. 

When  the  dilatation  becomes  permanent  surgical  interference  is  necessary. 
Excision  of  a  portion  of  the  enlarged  vessel  is  followed  by  a  temporary  increase 
of  swelling,  but  ultimately  by  cure. 

Balanitis  and  Balanoposthitis. — Balanitis  is  an  inflammation  of  the 
surface  of  the  glans  penis,  balanoposthitis  is  of  both  this  surface  "and  the  inner 
layer  of  the  foreskin. 

Causesr — The  principal  predisposing  cause  is  a  redundant  or  phimotic  fore- 
skin. This  keeps  the  apposed  surfaces  macerated  and  irritated,  favors  retention 
and  consequent  decomposition  of  smegma  and  urine,  and  offers  conditions  most 
propitious  to  a  successful  inoculation  when  specific  virus  is  introduced  within  the 
preputial  sac.  The  gouty  or  rheumatic  diathesis  and  diabetes  also  predispose 
to  this  form  of  inflammation. 

Infection  of  a  predisposed  surface,  usuall}^  by  pus  organisms,  is  the  exciting 
cause. 

Symptoms. — The  symptoms  of  balanitis  in  its  mildest  form,  from  which 
most  men  who  are  not  careful  as  to  local  cleansing  suffer  at  times,  are  a  sense 
of  heat  and  itching  about  the  end  of  the  penis,  some  redness  and  swelling  near 
the  preputial  orifice,  a  discharge  which  crusts  and  is  extremely  offensive,  and  on 


SURGERY  OF  THE  PENIS 


109 


Stripping  back  the  foreskin  a  hyperaemic  infiltrated  integument  exhibiting  on  its 
surface  a  thick,  creamy  deposit,  and  at  times  patches  of  superficial  excoriation 
(Fig.  57).  In  the  coronary  sulcus  is  found  an  abnormal  quantity  of  semi- 
liquid,  offensive  smegma. 

In  severe  cases  the  excoriations  are  extensive  and  well  marked,  inflammatory 
phenomena  are  more  pronounced,  and  the  whole  prepuce  becomes  greatly  swollen, 
and  in  consequence  phimotic  (inflammatory  phimosis) .  The  discharge  is  profuse. 
This  form  is  often  secondary  to  gonorrhoea,  chancroids,  syphilitic  lesions,  or 
general  troubles,  such  as  diabetes.  It  is,  however,  not  due  to  the  direct  action 
of  specific  germs  of  the  venereal  disease,  the  gonococcus,  for  example,  but .  to 


Fig.  57. — Balanitis. 

the  irritation  incident  to  tne  contact  with  decomposing  discharges  and  to  infec- 
tion with  the  ordinary  staphylococci. 

In  certain  cases  the  erosions  and  superficial  ulcerations  start  from  the  corona, 
exhibit  circinate  borders,  and  progressively  involve  the  entire  surface  of  the 
glans  and  foreskin,  lasting  for  several  weeks,  and,  so  far  as  extension  is  concerned, 
resisting  all  treatment. 

As  a  consequence  of  balanoposthitis  there  may  develop:  (1)  lymphadenitis; 
(2)  condylomata;    (3)  hypertrophy;    (4)  gangrene. 

Lymphadenitis,  at  least  the  suppurative  form  of  the  affection,  is  rare. 

Condylomata  frequently  develop  during  or  after  balanoposthitis. 

Hypertrophy  of  the  foreskin,  in  the  sense  of  a  greatly  elongated,  thickened, 
rigid  prepuce,  interfering  with  physiological  activity,  may  result  in  consequence 
of  organization  of  the  inflammatory  infiltration  consequent  on  repeated  attacks 
of  acute  or  subacute  inflammation.  It  is  noticed  in  middle-aged  men,  especialh' 
diabetics.    It  is  sometimes  followed  by  epithelioma. 


110  GENITO-URINARY  SURGERY 

When  the  inflammation  is  hyperacute,  inflammatory  swelling  may  be  fol- 
lowed by  gangrene.  This  is  scarcely  possible  except  in  phimotic  cases.  There 
is  little  danger  to  life  in  this  process,  which  is  self-correcting.  There  may  be, 
however,  ultimate  cicatricial  deformity. 

Diagnosis. — The  superficial,  irregular,  or  circinate  erosions,  together  with 
the  surrounding  surface  hyperaemia  and  the  characteristic  discharge,  render 
diagnosis  fairly  easy  when  the  foreskin  can  be  retracted. 

Herpes  at  first  exhibits  vesicles,  and,  when  these  vesicles  have  ruptured, 
circinate  lesions.  The  distinction  between  these  and  the  erosions  of  balano- 
posthitis  is  not  always  possible,  nor  is  it  important. 

Chancroidal  balanoposthitis  develops  insidiously,  is  characterized  by  an  in- 
flammatory infiltration  or  thickening  or  hardening  of  the  glans  and  foreskin 
rather  than  by  an  acute  oedema,  exhibits  more  distinctly  circumscribed  erosions, 
which  are  shortly  converted  into  true  ulcers,  and  is  soon  followed  by  char- 
acteristic inguinal  adenopathy. 

Syphilitic  balanoposthitis,  occurring  as  a  secondary  lesion,  is  diagnosed  by 
the  history  of  the  case,  the  appearance  of  characteristic  lesions  on  other  surfaces 
of  the  body,  and  the  development  of  moist  papules  primarily,  after  which 
neglect  of  treatment  may  occasion  a  general  inflammation  of  the  preputial  sac. 

Only  in  case  of  purulent  discharge  complicated  by  tight  phimosis  there  is 
difficulty  in  deciding  between  balanoposthitis  and  chancre,  chancroid,  and 
gonorrhoea.  In  such  cases  incision  of  the  prepuce  is  usually  indicated  to  render 
the  lesions  accessible  for  inspection  and  treatment. 

Treatment. — The  basis  of  all  treatment  is  cleanliness.  If  the  prepuce  can  be 
retracted,  the  inflamed  surfaces  are  washed  with  a  mild  antiseptic  solution, 
dilute  subactetate  of  lead  lotion,  or  bichloride  solution  1  to  4000,  dried  by 
means  of  absorbent  cotton,  and  the  erosions  brushed  with  a  ten  per  cent,  silver 
nitrate  solution;  the  parts  are  then  dusted  with  a  powder  made  of  equal  parts 
of  bismuth  subnitrate  and  calomel,  a  very  thin  layer  of  absorbent  cotton 
is  placed  over  the  glans,  and  the  foreskin  is  drawn  forward.  This  dressing 
should  be  changed  several  times  daily. 

WTien  the  discharge  is  profuse,  very  finely  powdered  alum  or  tannin  may 
be  used  in  place  of  the  calomel  and  bismuth.  Lumpy  or  gritty  dusting  powders 
do  more  harm  than  good. 

When  the  inflammation  is  unusually  acute  and  erosions  are  extensive,  a  wet 
dressing  is  indicated.  Under  such  circumstances,  after  washing,  the  dusting 
powder  and  silver  nitrate  are  omitted,  the  thin  layer  of  dry  cotton  being  placed 
directly  on  the  glans  and  then  wet  with  the  required  solution,  preferably  lead 
water,  or  fluidextract  of  hydrastis  canadensis  one  part,  rose  water  nine  parts. 
In  phimotic  cases  the  preputial  sac  should  be  washed  out  every  two  hours,  first 
with  warm  water  and  soap,  then  with  clear  water, -and  then  with  mild  antiseptic 
solutions,  such  as  sublimate  1  to  4000,  or  carbolic  acid  1  to  500,  or,  better 
still,  a  solution  containing  both  these  antiseptics  in  the  proportion  just  given, 
by  means  of  a  hard-rubber  syringe  provided  with  a  conical  nozzle.  The  whole 
preputial  sac  should  be  ballooned  out  with  the  solution,  unless  great  pain  is 
caused  by  this  distention.     Following   the  antiseptic  injection   the  hydrastic 


SURGERY  OF  THE  PENIS 


111 


solution  1  to  10  should  be  used.  When  suppuration  is  very  profuse,  peroxide 
of  hydrogen  may  precede  the  antiseptic  injection. 

General  swelling  of  the  prepuce  is  combated  by  keeping  the  parts  wrapped 
in  gauze  wet  in  dilute  alcohol  and  lead  water  equal  parts. 

Chancroidal  balanoposthitis,  or  that  complicating  diabetes,  is  alone  liable  to 
occasion  such  marked  swelling  as  to  require  splitting  of  the  foreskin.  Good 
results  may  be  obtained  by  following  the  procedure  described  under  "  Chancroid  " 
(see  p.  126).  In  diabetic  cases,  in  this  region  as  elsewhere,  rigid  cleanliness  is  of 
especial  importance. 

Herpes  Progenitalis. — This  affection  is  characterized  by  the  rather  sudden 
appearance  of  vesicles  clustering  upon  erythematous  bases,  and  attended  with 
itching  and  burning  (Fig.  58).    Commonly  they  appear  in  or  about  the  coronary 


^^W] 


Fig.  5  8-^Herpes  of  the  glane. 

sulcus,  involving  both  the  glans  and  the  foreskin.  When  thus  placed  the  cover- 
ing of  these  vesicles  is  quickly  macerated,  leaving  rounded  or  irregular  erosions 
which  may  become  confluent  but  still  exhibit  a  polycyclic  outline.  A  mild 
balanoposthitis  usually  complicates  herpes;  the  affection  sometimes  causes 
suppurating  buboes.     Warts  frequently  develop. 

When  these  lesions  are  neglected  the  abrasions  may  be  converted  into 
punched-out  ulcers  (ulcerating  herpes). 

Sometimes  the  lesions  are  accompanied  by  intense  pain,  much  like  that  of 
herpes  zoster;  the  affection  is  then  termed  neuralgic  herpes.  The  pain  may 
precede  the  development  of  the  vesicles,  which  may  be  so  few  and  discrete  as  to 
attract  little  attention.  The  burning,  shooting  pain  is  generally  confined  to  the 
penis;  occasionally  it  is  reflected  to  the  perineum  and  the  groins,  and  even 
down  the  thighs.  This  neuralgic  herpes  is  sometimes  accompanied  by  urethral 
discharge  simulating  gonorrhoea,  but  differing  from  it  in  the  absence  of  gonococci. 


112  GENITO-URINARY  SURGERY 

This  discharge  is  not  favorably  influenced  by  local  or  general  treatment.  Excep- 
tionally there  is  marked  sexual  erethism,  causing  prolonged  erections  and  noc- 
turnal pollutions. 

Herpes  having  once  appeared  is  prone  to  develop  again;  at  times  the  re- 
currence is  observed  hard  upon  the  first  attack,  new  crops  of  vesicles  forming 
as  fast  as  earlier  lesions  are  healed.  More  frequently  there  is  a  distinct  interval 
between  attacks.  When  it  has  this  tendency  to  relapse  it  is  called  recurrent, 
and  is  often  neuralgic  in  type. 

Herpes  appearing  upon  the  outer  surface  of  the  prepuce  does  not  differ  .from 
the  eruption  as  observed  on  other  surfaces  of  the  body.  The  eruption,  wherever 
it  is  situated,  may  be  discrete,  even  to  the  extent  of  the  formation  of  but  one  or 
two  vesicles,  or  confluent,  forming  in  this  case  usually  small  patches,  sometimes 
completely  covering  large  surfaces  and  causing  intensely  painful  inflammatory 
erosions. 

In  women  the  pain  accompanying  herpetic  eruptions  on  the  genitalia  may 
be  of  crippling  severity. 

Etiology. — The  causes  of  herpes  are  practically  the  same  as  those  of  balano- 
posthitis.  The  eruption  is  predisposed  to  by  rheumatism,  gout,  and  a  neurotic 
tendency;  also  locally  by  any  causes  tending  to  excite  inflammation,  such  as 
phimosis  and  urethral  or  preputial  discharges.  The  mechanical  irritation  of 
immoderate  coitus,  together  with  the  effect  of  prolonged  contact  with  any  irri- 
tating uterine  or  vaginal  discharge,  may  be  an  exciting  cause.  Neuralgic  herpes 
is  an  expression  of  local  circulatory  disturbance  due  to  nerve  lesion. 

Diagnosis  of  herpes  is  founded  upon  the  rather  sudden  appearance  of  vesicles 
in  clusters,  either  without  obvious  cause  or  following  closely  upon  mechanical 
or  chemical  irritation.  When  the  lesions  are  observed  in  their  vesicular  stage 
they  cannot  well  be  confounded  with  any  other  aft'ection.  When  they  are  placed 
■on  the  moist  surfaces  of  the  glans  and  foreskin,  however — and  this  is  their  usual 
situation — they  are  rarely  observed  before  the  coverings  of  the  vesicles  have  been 
macerated  and  the  lesions  are  erosive  or  ulcerative  in  type.  Even  then  they  are 
usually  superficial,  multiple,  circular,  or,  when  confluent,  at  least  circinate  in 
type,  nonindurated,  except  when  placed  at  or  within  the  urethral  orifice,  rapid 
in  development,  nonprogressive,  with  moist,  red  surface;  when  squeezed  they 
give  a  slight  serous  discharge.  If  kept  clean  rapid  healing  ensues,  though  new 
lesions  may  occur  on  previously  healthy  surfaces. 

The  differential  diagnosis  must  be  made  from  chancre,  chancroid,  balano- 
posthitis,  and  mucous  patches  (see  p.  117).  The  lesions  of  balanoposthitis  are 
usually  more  diffuse  and  rather  irregular  or  serrated  than  polycyclic  in  outline. 
Moreover,  they  are  not  preceded  by  vesicles.  The  differential  diagnosis  cannot 
always  be  made,  since  herpes  is  generally  accompanied  by  more  or  less  balano- 
posthitis. Mucous  patches  are  accompanied  bj^^  other  manifestations  of  syphilis, 
are  slower  in  development  than  herpes,  do  not  begin  as  vesicles,  and  present  a 
grayish  necrotic  pseudomembrane  in  place  of  the  red,  moist,  shining  surface  of 
the  herpetic  lesion. 

Treatment. — Cleanliness  is  the  key-note  of  successful  treatment.  Antiseptit 
washings,  careful  drying,  painting  with  silver  nitrate,  dusting  with  zinc  oxide  or 
bismuth,  the  interposition  of  a  thin  layer  of  cotton  between  the  two  moist 
surfaces,  and,  if  necessary,  the  remainder  of  the  treatment  described  as  appro- 


SURGERY  OF  THE  PENIS  113 

priate  to  balanoposthitis,  ordinarily  bring  about  cure  in  a  few  days.  Wlien  the 
inflammation  is  more  than  usually  acute,  a  wet  dressing  should  be  substituted 
for  the  dusting  powder.    In  the  ulcerating  form  the  system  is  usually  at  fault. 

Neuralgic  herpes  is  often  benefited  by  painting  with  silver  nitrate  solution 
ten  grains  to  the  ounce,  or  solution  of  chloral  one  drachm  to  the  ounce,  or  carbolic 
acid  lotion  1  to  60;  the  erosions  should  then  be  dressed  as  already  described. 
This  form  of  herpes  is,  however,  not  readily  influenced  by  local  treatment, 
though  spraying  with  four  per  cent,  cocaine  solution  may  relieve  the  pain, 
or  the  following  ointment  may  be  applied: 

Cocainee  hydrochlor.,   gr.   xii 
Menthol,  gr.  i 
.   Lanolin,  3iv 
M.   S. — Use  locally. 

Hypodermics  of  morphine  are  indicated  in  the  more  severe  cases,  they  not 
being  required  for  more  than  three  or  four  days,  particularly  if  the  patient  has 
been  subjected  to  the  eliminating  treatment  appropriate  to  gout,  rheumatism, 
or  other  underlying  cause  of  the  nerve  lesion. 

Recurrent  herpes  is  most  frequently  observed  in  connection  with  a  re- 
dundant or  phimotic  prepuce  or  stricture.  The  cure  of  these  conditions  often 
brings  permanent  relief.  When  there  seems  to  be  no  local  predisposing  factor, 
the  surfaces  most  often  affected  should  be  frequently  bathed  in  aqueous  solutions 
of  hydrastis  extract  1  to  5,  or  hot  saturated  solution  of  alum,  and  after  exposure 
to  any  form  of  irritation  should  be  thoroughly  cleansed  with  mild  antiseptic 
lotions,  washed  with  the  astringent,  carefully  dried,  and  dusted  with  stearate  of 
zinc  or  bismuth,  or  carbolized  talc.  A  general  tonic  and  supporting  dietetic 
and  medicinal  treatment  should  be  prescribed  at  the  same  time,  minute  doses 
of  arsenic  and  bichloride  of  mercury  (grain  one-sixtieth  of  each  t.  i.  d.)  and  the 
less  irritating  iron  preparations  being  particularly  indicated. 

CHANCROID 

The  chancroid  is  a  contagious  venereal  ulcer.  It  has  no  distinct  period  of 
incubation,  is  inflammatory  and  destructive  in  type,  and  is  frequently  accom- 
panied by  suppurating  buboes.  It  is  a  local  and  not  a  constitutional  disease. 
It  has  been  variously  named  soft  chancre,  simple  chancre,  and  noninfecting  sore. 

Cause. — While  multitudes  of  other  bacteria  are  regularly  found  in  chancroidal 
sores,  the  cause  of  the  lesions  is  a  short,  thick,  slightly  dumb-bell-shaped  strepto- 
bacillus,  known  as  the  bacillus  of  Ducrey.  Often  present  in  very  small  numbers 
in  the  original  sore,  and  for  this  reason  difficult  to  recognize,  in  the  ulcers  obtained 
by  experimental  inoculation  these  bacteria  are  found  in  much  larger  numbers, 
often  in  pure  culture.  Ducrey's  bacillus  is  decolorized  by  Gram's  method,  is 
stained  readily  with  the  ordinary^  aniline  dyes,  and  is  difficult  to  cultivate  on 
artificial-  media. 

Inoculability  of  Chancroid. — Auto-  and  hetero-inoculation  are  almost  invari- 
ably successful  when  performed  with  the  pus  of  chancroids  of  short  duration,  the 


114 


GENITO-URINARY  SURGERY 


inoculation  being  accomplished  by  abrading  the  skin  with  the  point  of  a  knife 
and  rubbing  in  a  minute  quantity  of  the  chancroidal  secretion.  In  from  one  to 
four  days  a  pustule  appears,  which  develops  into  a  typical  chancroidal  ulcer. 
After  repeated  inoculations  in  one  region  a  relative  immunity  is  developed, 
which  does  not  affect  the  remainder  of  the  body,  and  disappears  in  the  course 
of  a  few  months. 

Frequency  of  Chancroids. — Chancroids  are,  in  hospital  practice  at  least 
(and  especially  in  Europe),  more  frequently  encountered  than  chancres,  but 
among  the  well-to-do  the  chancre  is  more  frequently  seen  than  is  the  soft  sore. 

The  Localization  of  the  Chancroid. — The  chancroid  may  be  placed  upon  any 
cutaneous  or  exposed  mucous  surface.  It  is  usually  located  on  or  about  the 
genitalia;  extragenital  chancroid  is  far  less  frequent  than  extragenital  chancre. 

Genital  chancroids  in  the  male  are  usually  found  upon  the  glans  and  the 
prepuce  (Plate  VI).    The  favorite  positions  are  at  or  near  the  frsenum,  in  the 


Fig.  59. — Multiple  chancroids  of  the  coronary  sulcus. 

coronary  sulcus  (Fig.  59),  along  the  margin  of  the  prepuce,  on  the  moist  surfaces 
of  the  glans  and  the  foreskin,  and  at  the  urethral  orifice. 

In  females  these  lesions  are  found  along  the  margins  of  the  greater  and 
smaller  labia,  about  the  fourchette,  and  in  the  region  of  the  urinary  meatus 
(Fig.  60). 

Anal  chancroid  is  much  more  frequent  in  women  than  in  men.  In  them 
it  is  commonly  due  to  infection  of  cracks  or  fissures  about  the  rectal  opening 
by  the  contagious  discharge  which  flows  backward  from  the  vulva.  The  chan- 
croid is  usually  multiple. 

Pathology  of  Chancroid. — The  chancroidal  ulcer  is  made  up  of  a  small,  round- 
celled  infiltrate,  somewhat  sharply  limited  in  depth,  but  extending  considerably 
beyond  the  borders  of  the  ulcer,  and  invading  papillae  which  are  still  covered 
with  apparently  healthy  epithelium.    These  papillae  undergo  marked  hypertrophy. 

The  blood-vessels  are  dilated  and  increased  in  number,  and  exhibit  in  the 
adventitia  an  inflammatory  infiltration.  The  lymphatic  vessels  are  also  abnor- 
mally numerous,  and  open  directly  into  the  ulcer. 


PLATE  VI. 


A 
Chancroids  of  the  prepuce. 


B 

Epithelioma  of  glans. 


SURGERY  OF  THE  PENIS 


115 


THE  CLINICAL  ASPECTS  OF  CHANCRCiD 

Chancroid  as  acquired  by  coitus  differs  somewhat  in  its  cHnical  aspects  from 
that  caused  by  intentional  inoculation.  The  pustular  stage  is  rarely  observed, 
the  patient  not  detecting  the  lesion  until  an  ulcer  has  developed,  since  the  chan- 
croid is  usually  so  placed  that  the  thin  skin  covering  the  pustule  is  quickly 
macerated.  The  acquired  chancroid  frequently  seems  to  have  a  period  of  incu- 
bation varying  from  three  to  seven  days;  exceptionally  the  apparent  incubation 
is  much  longer;  generally  this  is  because  the  sore  is  not  noticed  in  its  early 
stages.  Ricord  explains  these  cases  on  the  theory  that  the  virus  is  deposited  on 
healthy  surfaces,  which  subsequently  becoming  eroded  offer  an  entrance-point  to 
the  microorganisms. 


Fig.  60. — Chancroid  of  labium  major. 


The  shape  of  the  chancroid  depends  upon  the  shape  of  the  eroded  surface 
through  which  inoculation  takes  place,  and  also  upon  the  anatomical  peculiarities 
of  the  part.  Thus,  inoculation  of  a  "  hair-cut  "  is  followed  by  a  linear  chancroid 
the  inoculation  of  an  extensive  abrasion  by  a  sore  corresponding  in  outlines 
with  this  abraded  surface.  The  lesions  of  herpes  preserve  their  general  out- 
line, but  take  on  chancroidal  ulceration.  An  infected  follicle  forms  first  a  hard, 
rounded,  elevated  lesion  resembling  a  furuncle.  This  rapidly  breaks  down  and 
discharges,  exposing  a  characteristic  chancroidal  ulcer  (Fig.  61).  When  the 
chancroid  involves  the  sides  of  the  fraenum  it  forms  a  long,  irregularly  shaped 
lesion,  which  not  infrequently  causes  complete  destruction  of  this  bridle.  When 
it  is  placed  in  the  coronary  sulcus  it  has  a  tendency  to  extend  in  the  direction 


116 


GENITO-URINARY  SURGERY 


of  this  furrow  (Fig.  62).    When  it  attacks  the  anus  it  spreads  in  the  direction 
of  the  skin-folds  of  this  region. 

Symptoms. —  (1)  There  is  no  period  of  incubation;  (2)  the  lesions  are  mul- 
tiple (Plate  VII,  Fig.  63);  (3)  they  begin  as  pustules  or  ulcers  and  are  rapid 
in  their  course;  (4)  they  form  ragged,  punched-out,  often  undermined  ulcers, 
irregular  in  shape,  discharging  freely,  inflammatory  m  type,  and  covered  with  a 
gray,  pus-soaked  slough,  which  may  be  concealed  by  a  thick,  moist  scab;  (5) 
they  produce  similar  lesions  on  surfaces  with  which  they  come  in  contact,  and 
their  discharge  can  be  inoculated  on  any  portion  of  the  surface  of  the  body; 
(6)  they  are  not  indurated;  (7)  scrapings  from  their  surfaces  show  pus  and 
shreds  of  necrotic  tissue,  but  no  epithehum;  (8)  they  are  frequently  complicated 
by  inflammatory  bubo. 


FIG.  61. — Follicular  chancroid. 

A  positive  diagnosis  cannot  be  founded  on  any  one  of  these  characteristic 
features  of  the  sore,  but  must  rather  be  based  upon  associated  symptoms.  While 
the  lesions  are  often  multiple,  this  is  by  no  means  an  invariable  rule.  The 
characteristic  feature  in  regard  to  the  multiplicity  of  chancroids  is  that  they 
generally  appear  not  simultaneously,  but  successively — i.e.,  from  auto-inocula- 
tion; though  when  several  abrasions  are  inoculated  at  the  same  time  the  multiple 
lesions  will,  of  course,  develop  coincidently. 

Though  the  disease  usually  begins  as  a  pustule  or  an  ulcer,  its  first  manifes- 
tation may  take  the  form  of  a  more  or  less  indurated  papule,  in  which  acute 
inflammatory  phenomena  may  progress  with  comparative  slowness.  The  follicu- 
lar chancroid  sometimes  develops  in  this  way.  Exceptionally  the  chancroid 
appears  as  a  purely  superficial  lesion,  its  nature  not  being  suspected  until  it 


PLATE  VII. 


Multiple  chancroids.    (Fox.) 


SURGERY  OF  THE  PENIS 


117 


assumes  typical  chancroidal  characteristics  or  causes  other  chancroids  by  auto- 
inoculation. 

Sometimes  chancroids  are  indurated;  this  is  particularly  true  of  the  follicular 
chancroid  and  of  those  sores  which  have  been  cauterized;  When  the  chancroids 
are  seen  early  and  are  carefully  treated  suppurating  buboes  are  the  exception 
rather  than  the  rule. 

What  might  be  called  the  natural  auto-inoculation — that  is,  the  production 
of  other  and  similar  sores  upon  healthy  surfaces  with  which  the  first  lesion  comes 
ill  contact — is  one  of  the  strongest  reasons  for  pronouncing  an  ulcer  chancroidal 
in  nature,  since  this  rarely  takes  place  from  other  forms  of  ulceration. 

Diagnosis. — Chancroid  must  be  distinguished  from  chancre,  from  herpes, 
from  follicular  abscess,  from  erosions  of  balanitis  and  balanoposthitis,  from  ulcer- 


FiG.  62. — Exulcerating  or  superficial  chancroid. 

ating  papular  syphilides,  from  ulcerating  gummata,  and  from  tuberculous  ulcera- 
tions. 

The  distinction  between  the  soft  sore  and  the  chancre,  the  one  which  the 
surgeon  most  frequently  will  be  called  upon  to  make,  is  sometimes  extremely 
difficult,  and  may,  indeed,  be  quite  impossible  except  by  finding  the  typical  or- 
ganisms in  the  serum  exuding  from  a  rubbed  or  scraped  sore  which  has  not  been 
treated  by  antiseptics.  The  chancroidal  and  syphilitic  infections  may  both  be 
present,  in  which  case  the  rapidly  progressive  and  destructive  inflammation  of 
chancroid  may  completely  mask  the  indurating  lesion  of  chancre.  The  typical 
features  of  each  sore,  with  a  diagnostic  table,  have  been  set  forth  in  another 
part  of  this  work  (see  p.  699),  but  it  is  not  amiss  to  call  attention  here  to 
the  fact  that  the  chancroid  may  be  indurated,  while  the  chancre  may  not  be. 


118  GENITO-URINARY  SURGERY 

In  the  chronic  chancroid  attacking  the  vulva  of  women,  the  secondary  hardening 
may  be  so  absolutely  like  that  of  the  primary  lesion  of  S5^hiUs  as  to  deceive 
the  most  skilled.  Again,  chancroid  may  cause  chronic  enlargement  of  several 
of  the  inguinal  lymphatic  glands,  thus  departing  from  its  type,  while  chancre 
may  make  a  parallel  variation  by  causing  suppurative  lymphadenitis. 

In  typical  cases  a  distinction  may  be  readily  made,  but  in  those  which  are 
atypical  in  the  absence  of  bacteriological  findings  the  surgeon. should  not  commit 
himself  to  a  positive  opinion. 

The  lesions  of  herpes,  follicular  abscess,  the  erosions  of  balanitis  and  balano- 
posthitis,  or  mechanical  abrasions  may  readily  be  mistaken  for  chancroids  when 
they  first  appear.    In  a  few  days,  at  most,  the  superficial  nature  of  the  inflam- 


FiG.  63. — Phagedaenic  chancroid. 

mation  and  the  prompt  yielding  to  cleansing  applications  show  that  chancroidal 
infection  is  absent. 

Ulcerating  papular  syphilides  when  found  upon  the  genitalia  closely  resemble 
chancroids,  but  are  slower  in  their  course,  are  less  inflammatory  in  type,  and 
other  lesions  of  the  disease  are  exhibited;  a  history  of  preceding  syphilitic  infec- 
tion usually  may  be  elicited,  and  the  spirochaete  may  be  found  in  the  serous 
exudate  of  a  mucous  patch. 

Ulcerating  gummata  of  the  genitalia  produce  lesions  indistinguishable  in 
appearance  from  chancroids.  Here,  again,  however,  a  history  of  syphilis,  the 
development  of  a  tumor  preceding  ulceration,  the  slow  progress  of  the  lesion 
(weeks  instead  of  days),  the  absence  of  the  symptoms  of  acute  inflammation, 
and  the  effect  of  constitutional  treatment  lead  to  a  correct  diagnosis. 

Tuberculous  ulcers  are  extremely  rare;  they  cannot  be  distinguished  from 
chancroidal  lesions  by  inspection  alone.    They  have,  however,  a  history  of  very 


SURGERY  OF  THE  PENIS 


119 


slow  extension  (weeks  or  months),  are  usually  associated  with  tuberculous 
lesions  in  other  parts  of  the  body,  sometimes  exhibit  about  the  periphery  of 
the  ulceration  grayish,  semitransparent,  miliary  tubercles,  and  on  microscopic 
examination  of  the  scrapings  of  the  lesion  often  show  the  tubercle  bacillus. 
Moreover,  inoculation  in  guinea-pigs  will  after  a  time  disclose  the  true  nature  of 
the  lesion. 

Sometimes  a  differential  diagnosis  can  be  made  only  by  auto-inoculation — 
a  valuable  means  of  determining  the  presence  or  absence  of  the  chancroidal 
virus,  but  one  which  is  not  infallible.  Its  value  is  perhaps  best  formulated  by 
stating  that  the  majority  of  chancroids  will  produce  ulcers  of  a  similar  type  on 
auto-inoculation,  while  the  majority  of  other  ulcers,  either  syphilitic,  tuber- 
culous, or  inflammatory,  will  not  produce  such  lesions. 

Complications  of  Chancroid 

1.  Phimosis  and  paraphimosis;  2,  Excessive  inflammation,  phagedsena,  and 
gangrene;  3,  Lymphangitis  and  lymphadenitis. 

Of  all  these  complications  lymphadenitis,  or  bubo,  is  by  far  the  most  common. 


Fig.  64. 


-Chancroidal  phimosis.  _  Secondary  chancroids  about  the  preputial 
orifice. 


Phimosis. — This  forms  a  serious  complication  of  chancroid,  mainly  because 
it  prevents  the  ulcer  from  being  efficiently  treated  and  causes  retention  of  dis- 
charge, and  consequently  favors  the  occurrence  of  acute  inflammation  and  the 
formation  of  inguinal  buboes  (Fig.  64). 

In  severe  cases  extensive  sloughing  and  gangrene  may  occur.    The  foreskin 


120  GENITO-URINARY  SURGERY 

becomes  dark,  almost  black,  cold,  nonresisting,  and  finally  melts  down  at  one 
or  more  points  into  a  putrid,  pultaceous  mass.  This  gangrenous  process  may 
attack  also  the  glans  penis,  and  partly  or  totally  destroy  it. 

Diagnosis. — The  diagnosis  of  subpreputial  chancroid  is  founded  upon  the 
severity  of  the  inflammatory  symptoms,  upon  their  persistence,  or  even  their 
aggravation,  in  spite  of  careful  treatment,  and  upon  the  result  of  auto-inoculation. 
At  times  palpation  elicits  local  tenderness,  and  the  inflammatory  induration 
of  the  lesion  may  be  recognized  by  touch  through  the  foreskin. 

Paraphimosis. — Patients  with  congenitally  short  prepuces,  or  those  whose 
foreskins  are  habitually  retracted,  frequently  suffer  from  paraphimosis  incident 
to  the  swelling  occasioned  by  chancroid;  or  this  condition  may  result  from 
retraction  of  the  foreskin  after  the  swelling  is  well  advanced,  as  it  is  then  often 
impossible  to  draw  it  forward.  This  complication  is  much  less  troublesome  than 
phimosis,  since  the  lesion  is  exposed  and  can  be  properly  treated.  It  occasions, 
however,  more  rapid  and  dangerous  congestion  than  phimosis,  and  usually  de- 
mands immediate  relief. 

Gangrene — ^Phagedaena. — Chancroids  may  be  unusually  inflammatory  in 
type  from  the  first,  or  after  a  comparatively  mild  course  may  suddenly  become 
acutely  inflamed. 

The  causes  of  this  are  usually  a  general  cachectic  condition,  local  irritation, 
and  disturbances  of  circulation,  as  from  phimosis  and  paraphimosis. 

In  these  cases  swelling  and  redness  extend  far  beyond  the  lesion  and  the 
whole  part  becomes  oedematous.  The  patient  complains  of  pain,  there  is  often 
a  mild  inflammatory  fever,  and  the  ulcer  rapidly  spreads. 

If  the  causes  producing  inflammation  remain  still  operative  and  prompt  treat- 
ment is  not  applied,  the  lesion  becomes  gangrenous ;  in  this  case  swelling  is 
more  pronounced,  and  large  areas  become  dusky  red,  dirty  brown,  and  finally 
quite  black  and  putrid.  In  a  very  few  hours  extensive  tissue-destruction  may 
result.  The  entire  penis  may  be  destroyed,  the  testicles  may  be  laid  bare,  and 
the  process  may  extend  far  up  the  belly-walls.  The  constitutional  symptoms 
are  pronounced. 

At  times  the  destructive  process  is  much  slower  in  its  course,  ultimately  pro- 
ducing lesions  quite  as  extensive,  but  rather  by  molecular  death.  The  ulcer 
steadily  extends,  in  spite  of  treatment,  until  it  attains  enormous  dimensions, 
exposing  the  blood-vessels  of  the  groins,  destroying  the  entire  scrotum,  eating 
far  back  along  the  perineum,  and  leaving  but  the  stump  of  the  penis.  This 
process  is  termed  phagedccnic,  and  is  never  observed  except  in  those  whose  systems 
are  profoundly  depressed.  Thus  it  is  encountered  in  diabetics,  or  in  those  suffer- . 
ing  from  scurvy  or  scrofula,  from  visceral  diseases,  such  as  chronic  hepatitis 
and  nephritis,  or  from  tertiary  syphilis. 

The  phagedsenic  ulcer  sometimes  lasts  for  months  or  years  manifesting  a 
tendency  to  heal  in  one  part  while  it  steadily  extends  in  another,  the  lines  of 
extension  often  having  a  circinate  or  serpentine  outline.  This  form  of  ulceration 
is  termed  serpiginous . 

Lymphangitis,  or  inflammation  of  the  lymphatic  vessels,  is  a  rare  compli- 
cation of  chancroid,  even  in  the  presence  of  suppurating  buboes.  Resolution 
usually  takes  place  under  appropriate  treatment. 


SURGERY  OF  THE  PENIS 


121 


Bubo,  or  lymphadenitis  (Fig.  65),  as  has  been  stated,  is  the  commonest 
complication  of  chancroid.  The  number  of  cases  suffering  from  this  compHcation 
varies,  according  to  different  reports,  from  five  per  cent,  to  thirty  per  cent,  of 
the  total  number  suffering  from  chancroid.  In  hospital  practice  about  one  out 
of  five  ambulant  chancroid  cases  develop  bubo;  in  office  practice  and  among 
the  well-to-do  this  complication  is  comparatively  rare,  on  account  of  earlier 
treatment.  The  glands  involved  are  generally  those  to  which  the  lymph-vessels 
supplying  the  seat  of  ulceration  pass  most  directly — i.e.,  the  group  of  glands 
lying  below  Poupart's  ligament,  above  the  saphenous  opening.  The  glands  lying 
near  the  middle  line  of  the  body  to  the  right  and  left  of  the  symphysis  pubis 


Fig.  65. — Chancroidal  bubo. 

generally  escape.  Adenitis  from  lesions  of  the  foot  or  leg  attacks  primarily  the 
glands  lying  just  below  the  saphenous  opening  in  the  course  of  the  long  saphenous 
vein. 

It  is  usual,  in  cases  of  sores  on  the  genitalia,  for  bubo  to  form  on  the  side 
of  the  body  corresponding  with  that  of  the  lesion,  but  this  rule  is  at  times 
reversed.  Lesions  of  the  fraenum  frequently  cause  bilateral  buboes  and,  indeed, 
sores  of  this  region  and  upon  the  prepuce  and  glans  are  followed  by  a  larger 
percentage  of  buboes  than  when  the  chancroids  are  located  on  any  other  part  of 
the  genitalia. 

Cause. — Aside  from  the  fact  that  retained  discharges  distinctly  predispose 
to  bubo,  the  character  of  the  sore  seems  to  have  little  influence  in  the  develop- 


122  GENITO-URINARY  SURGERY 

ment  of  this  complication.  Thus  a  sloughing  or  gangrenous  chancroid  will  run 
its  course  without  any  effect  upon  the  lymphatic  glands,  while  a  superficial  lesion 
the  size  of  a  split  pea  may  be  accompanied  by  a  double  suppurating  lympha- 
denitis. 

This  complication  usually  develops  from  the  second  to  the  fourth  week  of 
the  chancroid.  It  may,  however,  appear  almost  as  soon  as  the  lesion,  or  may 
develop  weeks  after  the  chancroid  has  been  completely  cicatrized. 

The  direct  cause  of  bubo  is  not  clearly  formulated.  It  has  not  been  demon- 
strated that  the  destructive  adenitis  is  invariably  due  to  the  action  of  microor- 
ganisms upon  the  gland.  Cultures  and  auto-inoculations  made  with  the  discharge 
of  buboes  give  negative  results,  and  microscopic  examination  of  such  discharge 
may  fail  to  show  bacteria.  The  degeneration  of  the  glands  is  probably  partly 
owing  to  the  presence  of  a  chemical  irritant  absorbed  from  the  ulcerating  surface. 

Symptoms. — The  bubo  usually  begins  with  a  sense  of  pain  on  motion  referred 
to  the  inguinal  region.  On  examination  there  is  found  a  hard,  tender  lump 
over  which  the  skin  is  freely  movable.  This  lump  steadily  increases  in  size, 
becomes  constantly  painful,  and  is  so  tender  that  the  patient  is  confined  to  his 
chair  or  bed.  The  overlying  skin  becomes  reddened,  adherent,  and  cedematous. 
The  patient  complains  of  rigors,  fever,  and  thirst,  and  finally  on  examination 
fluctuation  is  detected. 

The  pain  may  be  constant  and  severe;  sometimes  without  obvious  cause 
it  is  suddenly  relieved.  This  is  due  to  rupture  of  the  gland  capsule  and  escape 
of  its  contents  into  the  surrounding  tissue,  and  is  followed  by  rapid  increase 
of  swelling  and  breaking  down  of  the  periglandular  tissues. 

On  evacuation  of  the  suppurating  bubo,  thick,  blood-stained  pus  is  dis- 
charged, leaving  a  cavity  with  gray  and  necrotic  walls.  On  digital  examination 
of  this  cavity  it  is  often  possible  to  detect  several  swollen  glands  which  have 
been  involved  in  the  inflammatory  process  but  have  not  yet  been  completely 
destroyed.  These  are  felt  projecting  into  the  space  from  which  the  pus  has 
been  evacuated. 

Usually,  after  evacuation  of  the  pus  and  proper  surgical  treatment  of  the 
resulting  cavity,  healing  takes  place  promptly.  In  such  cases  the  lesion  is  said 
to  be  a  simple  bubo.  Exceptionally  soon  after  opening  the  bubo  its  whole  sur- 
face becomes  converted  into  a  huge  ulcer  corresponding  in  type  with  chancroid. 
This  is  termed  the  chancroidal  bubo  (Fig.  65).  Appropriate  treatment,  how- 
ever, shortly  converts  this  into  a  simple  ulcer,  which  ultimately  heals  kindly, 
though,  as  in  the  case  of  the  chancroid  itself,  inflammation,  gangrene,  or 
phagedsena  may  complicate  the  healing.  It  is  probable  that  the  bubo  is  never 
primarily  chancroidal,  but  becomes  so  by  inoculation  either  during  or  after 
operation. 

In  women  buboes  rarely  complicate  chancroids.  When  they  occur  they 
are  generally  found  in  the  inguinal  region,  the  lymphatic  vessels  about  the  vulva 
and  the  rectum  communicating  with  the  glands  of  the  groin. 

Prognosis. — The  chancroid  as  it  occurs  in  healthy  people,  and  especially  in 
those  who  are  cleanly  in  their  habits  and  who  scrupulously  follow  a  mild  anti- 
septic treatment,  runs  its  course  in  from  three  to  six  weeks  without  complication. 
Even  if  no  treatment  whatever  is  applied,  the  majority  of  chancroids  heal  spon- 


SURGERY  OF  THE  PENIS  123 

taneously  in  six  weeks.  During  the  whole  course  of  the  lesion,  and  even 
after  cicatrization  has  taken  place,  buboes  may  form,  and  prognosis  as  to  the 
avoidance  of  this  complication  should  be  extremely  guarded.  Except  in  the 
most  superficial  forms,  the  lesion  is  followed  by  scarring. 

Treatment   of    Chancroid 

Since  it  is  pretty  generally  conceded  that  chancroid  is  due  to  inoculation  with 
the  discharge  of  a  similar  lesion,  and  since  such  inoculation  takes  place  almost 
invariably  by  sexual  congress,  the  prophylaxis  of  chancroid  is  comparatively 
simple.  Where,  however,  this  means  {i.e.,  avoidance  of  exposure)  is  not  adopted, 
the  external  genitalia  should  be  thoroughly  washed  with  soap  and  water  and 
then  smeared  with  33  per  cent,  calomel  ointment,  the  ointment  being  allowed  to 
remain  on  the  parts  for  several  hours. 

Whatever  form  of  treatment  is  adopted,  the  end  to  be  attained  is  the  con- 
version of  the  unhealthy  spreading  ulcer  into  a  healing,  granulating  surface; 
Since  the  virulent  properties  of  the  chancroid  are  dependent  upon  the  presence 
of  microorganisms,  it  necessarily  follows  that  efficient  treatment  must  have  for 
its  end  either  an  inhibitory  or  a  destructive  action  upon  these  microorganisms, 
or  must  so  increase  the  local  resistance  that  the  lesion  cannot  spread.  Anti- 
septics in  some  form  are  indicated.  These  should  be  either  so  mild  that  they 
produce  little  or  no  irritation,  or  so  powerful  that  they  cause  total  destruction 
of  the  entire  diseased  area,  i.e.,  they  should  be  distinctly  cauterant. 

Under  the  application  of  mild  antiseptics  the  chancroid  is  usually  cured 
in  from  two  to  six  weeks.  Under  the  application  of  cauterants  a  cure  sometimes 
results  in  from  seven  to  fourteen  days. 

Satisfactory  results  may  be  obtained  by  the  observance  of  surgical  cleanliness, 
not  only  of  the  surface  of  the  sore,  but  also  of  the  surrounding  skin  or  mucous 
membrane.  After  thorough  washing  with  soap  and  hot  water,  a  spray  of  hydro- 
gen peroxide,  full  strength,  is  directed  on  the  chancroid  and  the  skin  near  it; 
this  is  followed  by  washing  or  spraying  with  carbolic  1  to  60  or  bicholoride 
1  to  3000. 

After  the  chancroid  and  the  surrounding  surfaces  have  been  cleansed,  the 
surgeon  may  conduct  the  treatment  with  either  non-irritating  antiseptic  applica- 
tions or  with  cauterants. 

Non-irritating  antiseptic  applications  may  be  made  in  the  form  of 
powders,  of  ointments,  or  of  lotions. 

Dry  Dressings. — The  powders  commonly  employed  are  iodoform,  aristol, 
iodol,  boric  acid,  calomel,  acetanilid,  zinc  stearate,  zinc  oxide,  and  bismuth  sub- 
nitrate.  None  of  these  are  strongly  antiseptic.  The  most  efficient  is  iodoform; 
this  has  practically  no  antiseptic  value,  but  in  the  presence  of  pus  undergoes 
decomposition,  the  products  of  which  have  a  distinct  inhibitory  effect  upon 
further  germ-growth.  The  objections  to  the  use  of  the  drug  are  its  penetrating 
odor  and  occasionally  the  production  of  violent  inflammation.  The  odor  may  be 
in  part  disguised  by  mixing  with  the  powder,  in  the  proportion  of  a  drop  to  a 
drachm,  oil  of  lavender  or  attar  of  roses,  or  finely  pulverized  coffee  in  the  pro- 
portion of  one  part  to  five  may  be  added  to  the  iodoform.  None  of  these 
expedients  will  be  found  perfectly  satisfactory. 


124  GENITO-URINARY  SURGERY 

In  applying  this  powder  it  is  important  to  bring  it  directly  in  contact  with  the 
ulcerating  surface;  when  it  is  placed  upon  the  surrounding  skin  or  upon  crusts 
covering  lesions  it  is  absolutely  useless.  It  can  be  dusted  upon  the  lesion  by 
means  of  a  small  pledget  of  cotton  which  is  first  rubbed  in  the  powder,  or  by  an  in- 
sufflator, or  in  the  form  of  a  spray  of  iodoform  in  ether.  It  should  be  used  only 
after  the  lesion  has  been  thoroughly  cleansed  by  hydrogen  peroxide  and  dilute 
antiseptics. 

lodol  and  aristol  have  similar  properties,  but  are  more  prone  to  form  crusts, 
thus  favoring  retention  of  discharge.  In  clinical  practice  they  have  been  found 
distinctly  less  efficient  than  iodoform.. 

Argyrol  in  substance  applied  after  cleansing  the  chancroid,  secured  by  band- 
age and  redressed  daily,  has  resulted  in  many  cures. 

Zinc,  calomel,  and  bismuth  are  mainly  efficient  as  drying  agents,  though  they 
undoubtedly  have  feeble  astringent  and  antiseptic  properties. 

Dusting  powders  should  never  be  allowed  to  form  with  the  secretions  scabs  or 
crusts,  thus  preventing  the  escape  of  discharges,  and  they  should  be  brought 
immediately  in  contact  with  granulating  surfaces.  Boric  acid  and  salicylic  acid 
are  sometimes  useful  as  dusting  powders,  and  are  less  prone  thus  to  form  crusts 
than  the  insoluble  preparations.  Salicylic  acid  is  often  so  irritating  that  its 
application  is  not  advisable. 

If  dry  dressings  are  used,  the  lesion  is  treated  from  one  to  six  times  a  day 
in  accordance  with  the  amount  of  discharge.  It  is  first  cleansed,  then  dried  by 
means  of  absorbent  cotton,  then  dusted  with  the  remedy  of  choice;  finally  a  thin 
sheet  of  absorbent  cotton  is  laid  over  it,  and  is  retained  in  position  by  straps  or 
bandages,  or  by  pulling  the  foreskin  forward. 

Dry  dressing  is  indicated  in  chancroids  of  moderate  severity  which  are  not 
inflammatory  in  type  and  which  do  not  discharge  profusely. 

Wet  Dressings. — In  place  of  the  dusting  powders,  after  thorough  cleansing 
of  the  lesions  and  surrounding  parts  there  may  be  placed  on  the  ulcerating 
surface  pledgets  of  cotton  wet  in  one  of  a  variety  of  mild  antiseptic  lotions. 
Of  these  the  most  efficient  are  Wright's  solution  (sodium  chloride,  4  per  cent.; 
sodium  citrate,  1  per  cent.);  carbolic  acid,  1  to  60;  bichloride,  1  to  3000;  phenol 
sodique,  1  to  6;  and  lead  water.  These  wet  cotton  pledgets  should  be  changed 
frequently,  especially  when  the  discharge  is  abundant.  This  is  readily  managed, 
since  the  patient  can  carry  with  him  a  small  bottle  of  the  antiseptic  solution  and 
some  cotton.  He  should  change  the  cotton  pledget  each  time  he  urinates.  The 
dressing  is  kept  in  place  by  the  foreskin  in  many  cases,  or  by  straps,  bandages, 
jock-straps,  or  swimming-tights. 

The  wet  dressing  is  especially  indicated  in  patients  whose  inclination  or  sur- 
roundings prevent  them  from  carrying  out  the  cleansing  required  in  dry  dressings, 
and  in  patients  whose  lesions  discharge  freely  and  are  inflammatory  in  t5Ape. 

Antiseptic  Ointments. — Ointments  used  in  treating  chancroids  have  for  their 
active  principle  a  drug  such  as  iodoform,  boric  acid,  salicylic  acid,  carbolic  acid, 
or  one  of  a  large  variety  of  similar  antiseptics.  They  are  most  useful  when  there 
is  a  tendency  to  form  crusts,  and  when  the  lesions  are  cicatrizing. 

Cauterization. — Immediate  and  complete  destruction  of  a  chancroidal  ulcer 
is  the  safest  routine  treatment,  since  thus  its  virulent  qualities  are  immediately 


SURGERY   OF  THE  PENIS.  125 

destroyed  and  there  results  a  healthy  granulating  surface  which  quickl}^  cicatrizes, 
and  which,  if  kept  clean,  is  attacked  only  in  very  exceptional  circumstances  by 
the  complications  characteristic  of  chancroid.  The  main  objection  urged  against 
this  method  of  treatment  is  that  it  is  unnecessarily  severe,  since  the  majority 
of  chancroids  will  heal  kindly  under  simple  antiseptic  dressings.  This  argument 
obtains  particularly  among  the  well-to-do,  who,  by  careful  observance  of  treat- 
ment, usually  recover  promptly.  In  dispensary  patients,  however,  and  in  those 
who  are  careless,  or  who,  from  their  surroundings,  cannot  treat  chancroids  in 
accordance  with  the  principles  of  surgical  cleanliness,  cauterization  is  particularly 
to  be  commended. 

For  cauterizing  chancroids,  nitric  acid,  sulphuric  acid,  caustic  potash,  bro- 
mine, iodine,  zinc  chloride,  copper  sulphate,  arsenious  acid,  and  the  actual  cautery 
have  all  been  successfully  employed. 

The  best  instrument  for  destroying  chancroids  is  the  actual  cautery;  this  may 
be  used  in  the  form  of  a  heated  iron,  Paquelin's  cautery,  or  the  galvano-cautery. 

In  performing  the  operation  the  chancroid  and  the  surrounding  healthy  area 
are  first  thoroughly  cleansed,  and  are  then  anaesthetized  by  means  of  a  hypo- 
dermic injection  of  a  one-half  per  cent,  solution  of  novocaine  driven  into  the 
cellular  tissue  wide  at  the  base  of  the  lesion.  The  cautery  at  a  white  heat  is  then 
applied,  so  that  not  only  the  chancroid  is  destroyed,  but  also  the  surrounding 
tissue  to  the  extent  of  one-eighth  of  an  inch  from  the  borders  of  the  sore.  The 
cautery  must  be  carried  to  every  recess  of  the  ulcer.  If  sinuses  are  present,  these 
must  be  slit  up  and  their  unhealthy  walls  cauterized.  If  the  minutest  portion  of 
the  sore  is  left  untouched  by  the  cautery,  the  probability  is  that  the  entire  lesion 
produced  by  the  operation  will  again  become  infected.  After  cauterizing,  the 
surrounding  parts  should  again  be  thoroughly  disinfected.  The  dry  eschar  result- 
ing from  the  burning  is  dusted  with  iodoform  and  protected  by  the  application  of 
a  little  absorbent  cotton.  In  from  three  to  five  days  this  eschar  comes  away, 
exposing  a  healthy  ulcer,  which  quickly  cicatrizes. 

Inflammatory  swelling  resulting  from  this  application  is  combated  by  the 
application  of  strips  of  gauze  wrung  out  of  lead  water,  or  lead  water  and  alcohol 
equal  parts,  and  kept  constantly  wet  with  this  solution. 

In  case  the  actual  cautery  cannot  be  employed,  nitric  acid  should  usually  be 
selected.  It  should  be  applied  to  the  anaesthetized  sore  by  means  of  a  bare 
wood  applicator,  every  part  being  thoroughly  and  deeply  cauterized.  The  after- 
treatment  is  the  same  as  after  the  use  of  the  actual  cautery.  Caustic  potash, 
iodine,  and  other  cauterants  are  employed  in  the  same  way. 

Cauterization  is  indicated  when  chancroids  are  seen  in  their  early  stages, 
when  they  are  rapidly  extending,  and  when  they  are  gangrenous,  phagedsenic, 
or  serpiginous. 

Cauterization  is  contra-indicated  when  the  inflammatory  swelling  incident  to 
its  use  would  probably  occasion  phimosis  or  paraphimosis,  when  the  chancroid 
is  markedly  inflamed  but  not  yet  sloughing  extensively,  and  when  the  lesion  has 
passed  through  its  virulent  stage  and  is  healing. 

High-frequency  Vacuum  Electrode. — This  is  doubtless  the  most  efficient 
treatment  for  chancroids.  The  sore  is  cleansed,  dried,  anaesthetized  with  a 
solution  of  cocain,  painted  with  a  25  per  cent,  solution  of  copper  sulphate  and 


126 


GEXITO-URINARY  SURGERY 


thoroughly  sparked  with  the  high-frequency  electric  current,  employing  the 
vacuum  electrode.  One  treatment  usually  suffices  to  sterilize  completely  the 
sore,  which  is  followed  by  healthy  granulation  and  prompt  healing. 

Operation. — Two  operations  have  been  suggested  and  carried  out  in  the  hope 
of  accomplishing  the  immediate  cure  of  chancroid. 

The  first  consists  in  a- thorough  curetting  of  the  lesion,  careful  antiseptic  wash- 
ing, and  dusting  with  iodoform  powder.  The  second  in  excision  of  the  lesion  and 
inmiediate  suture  of  the  resulting  wound. 

If  reports  of  cases  could  be  accepted  as  conclusive  evidence  in  favor  of  any 
treatment,  these  operations  should  be  universally  adopted.  Our  experience,  how- 
ever, has  not  corroborated  the  favorable  opinion  of  these  methods  advanced  by 
others. 

Treatment  of  the  Complications  of  Chancroid. — Phimosis. — When  the 
subpreputial  chancroid  is  complicated  by  phimosis,  efficient  treatment  is  rendered 
difficult  by  the  fact  that  the  sore  is  not  readily  accessible  and  by  the  retention 
of  discharge;  consequently  such  lesions  are  prone  to  become  inflammatory  in 


Fig.  66. — Phimosis  caused  by  chancroid  of  the  meatus,  treated  by  lateral 
incisions  (one  week  after  operation).  Note  the  relative  exposure  of  the  glans 
obtained  by  this  method  and  by  a  single  dorsal  incision  (FiG.  67),  both  wounds 
having  become  infected. 

type,  to  excite  cedema  and  congestion,  to  develop  phagedaenic  or  gangrenous 
symptoms,  and  to  be  complicated  by  buboes.  When  the  symptoms  of  inflam- 
mation are  moderately  severe,  satisfactory  results  may  be  obtained  by  the  fre- 
quent emplo3'ment  of  mild  antiseptic  subpreputial  washes  and  the  external 
application  of  evaporating  lotions.  Thus  the  whole  preputial  sac  may  be 
syringed  out  every  two  hours  with  hj^drogen  peroxide,  followed  by  mild  bichloride 
solution  (1  to  6000),  or  other  unirritating  antiseptic.  The  penis  should  be  kept 
elevated,  so  that  venous  congestion  may  be  diminished,  and  should  be  wrapped 
in  gauze  kept  wet  \^^th  alcohol  and  lead  water,  equal  parts  of  each;  or,  when  the 
circumstances  of  the  patient  are  such  as  to  permit  this  treatment,  subpreputial 
washes,  followed  by  prolonged  soaking  of  the  penis  in  water,  or  4  per  cent. 


SURGERY  OF  THE  PENIS 


127 


sodium  chloride  solution,  as  hot  as  can  be  borne,  are  at  times  most  efficacious  in 
reducing  inflammation.  The  soaking  should  last  for  an  hour,  and  should  be 
repeated  three  or  four  times  daily. 

If,  despite  this  treatment,  swelling  rapidly  increases,  and  it  is  evident  that 
the  chancroid  is  steadily  extending,  exposure  should  be  secured  by  means  of 
an  incision  in  each  side  of  the  prepuce  (Fig.  66).  A  general  anaesthetic  may 
be  given  for  the  operation,  or  local  anaesthesia  as  described  for  circumcision  may 
be  used.  The  operation  is  performed  with  a  pair  of  scissors,  one  blade  of 
which  is  slipped  along  a  grooved  director  to  the  bottom  of  the  preputial  sac, 
and  then  thrust  through  both  layers  of  the  foreskin;  the  incision  is  then  made 


Fig.   67. — Chancroidal  ulceration  of  an  incision  of  the  prepuce  requirerl  for  the  relief  of 

phimosis. 

with  one  cut,  after  which  the  operation  is  repeated  on  the  opposite  side.  The 
inner  and  outer  cut  margins  of  the  prepuce  should  be  united  by  sutures  to  limit 
the  size  of  the  •  granulating  area.  The  two  incisions  are  preferable  to  a  single 
dorsal  (Fig.  67)  on  account  of  the  better  exposure  of  the  region  of  the  fraenum 
afforded  by  this  method.  When  a  particularly  virulent  strain  of  organisms  is 
obviously  present  it  is  advisable  to  sear  the  cut  surfaces  with  the  cautery,  or 
better  still  to  make  the  incisions  with  a  cautery  knife.  Circumcision  is  to  be 
performed  after  healing  is  complete. 

The  objection  to  performing  circumcision  at  this  time  lies  in  the  fact  that 
the  operation  wound  is  usually  converted  into  a  chancroid.  Moreover,  when 
there  is  great  oedema,  there  is  difficulty  in  accurately  gauging  the  flaps.    These 


128  GEXITO-URINARY  SURGERY 

objections  are  not  of  sufricient  weight  to  cause  circumcision  to  be  rejected 
invariably;  indeed,  in  a  fair  proportion  of  cases,  when  every  antiseptic  precaution 
has  been  taken,  union  ma}-  be  almost  -as  prompt  as  when  nonchancroidal  lesions 
are  subject  to  operation.  There  can,  however,  be  no  certainty  that  the  circum- 
cision wound  "^ill  remain  healthy. 

Gangrene  and  Phagedena. — ^\Vhen  gangrene  develops,  the  first  indications 
are  to  relieve  constriction  or  pressure.  \Alien  it  complicates  a  phimosis  or  a 
paraphimosis,  these  conditions  should  receive  prompt  surgical  treatment.  The 
patient  must  be  kept  in  bed,  mth  the  involved  parts  elevated  and  wrapped 
in  hot  antiseptic  fomentations  frequently  changed.  These  ma}^  be  made  by 
wringing  out  pads  formed  of  twenty  or  thirty  la\-ers  of  gauze  wet  in  bichloride 
solution  (1  to  4000),  or  4  per  cent,  sodium  chloride,  as  hot  as  can  be  borne, 
enveloping  the  gangrenous  regions  in  these  pads,  and  covering  this  dressing 
^ith  oiled  silk  to  prevent  evaporation.  These  compresses  should  be  changed 
every  fifteen  minutes.  Prolonged  soaking  of  the  parts  in  hot  water  or  a  hot  mild 
antiseptic  solution  is  a  powerful  means  of  arresting  gangrene. 

If.  in  spite  of  treatment  by  heat,  the  gangrene  is  rapidl}'  extending,  the 
parts  already  devitalized  should  be  clipped  away,  and  the  ulcerated  and  raw 
surfaces  should  receive  a  thorough  application  of  the  actual  cautery,  or  of  nitric 
acid,  the  field  of  operation  being  subsequenth'  dressed  with  compresses  kept  wet 
with  lead  water  and  alcohol. 

In  all  cases  of  gangrene  the  constitutional  treatment  should  receive  careful 
attention  and  should  be  supporting  and  stimulating.  Iron,  quinine,  and  nux 
vomica  are  the  tonics  of  choice.  Potassio-ferric  tartrate  has  been  particular^ 
recommended.  Cod-liver  oil  will  be  found  beneficial  in  perhaps  the  majority 
of  cases." 

The  chronic  phagedaenic  chancroid  and  the  serpiginous  sore  are  so  invariably 
associated  with  constitutional  dyscrasia,  that  local  treatment  alone  is  powerless 
to  effect  a  cure.  Often  the  underlying  lesion  is  syphilitic  in  nature  and  appro- 
priate specific  treatment  will  be  followed  by  cure.  Frequentl}^  it  is  tuberculous 
or  is  dependent  upon  \isceral  lesions.  In  any  case  general  treatment  is  of 
cardinal  importance.  This  should  be  tonic  and  supporting  in  type.  Stimulants, 
cod-liver  oil,  the  h^-pophosphites,  and  arsenic  render  valuable  service.  Locally 
the  lesion  should  be  treated  in  accordance  "^ith  the  condition  of  the  granulating 
surface:  thus,  applications  of  silver  nitrate  ten  per  cent.,  or  copper  sulphate  of 
equal  strength,  followed  by  dusting  with  iodoform,  wall  sometimes  be  followed 
by  good  results.  Usually  these  and  other  mild  methods  of  treatment  are 
perfectly  futile.  In  such  cases  cauterization  of  the  entire  lesion,  followed  by 
packing  •uith  iodoform  gauze  and  the  application  of  an  antiseptic  dressing, 
may  accomplish  a  cure.  In  some  instances  a  continuous  warm  bath,  lasting 
for  days  or  even  weeks  has  caused  lesions  to  heal  which  had  resisted  every  other 
form  of  treatment.  Occasionally  such  cases  recover  when  complete  change 
of  air  and  surroundings  is  made,  supplemented  by  ordinary  clean  dressings. 

Autogenous  bacterins  are  sometimes  of  great  value.  McDonagh  recommends 
enormous  doses  of  potassium  iodide  as  being  almost  a  specific. 

Lymphangitis. — This  comparatively  rare  complication  of  chancroid  is  treated 
in  accordance  \\\\.\\  general  surgical  principles. 


SURGERY  OF  THE  PENIS  129 

Lymphadenitis  or  Bubo. — This  complication  of  chancroid  is  usually  avoided 
when  the  lesion  is  kept  thoroughly  clean  and  well  drained  from  the  first  and 
when  the  patient  remains  quiet.  Even  when  the  nodes  have  begun  to  swell, 
as  evidenced  by  pain  and  tenderness  in  the  groin  and  the  detection  of  a  distinct 
lump,  further  enlargement  can  often  be  prevented  by  rest  in  bed,  the  administra- 
tion of  a  saline  purge,  and  the  application  over  the  affected  region  of  heat  and 
pressure.  This  is  best  applied  by  means  of  lint  wet  with  lead  water.  Over  this 
is  laid  the  ordinary  rubber  hot-water  bag,  the  patient  lying  on  his  back  in  bed. 
Scrupulous  attention  must  be  paid  at  the  same  time  to  the  cleansing  of  the 
chancroid. 

When  this  treatment  by  rest  in  bed  and  application  of  heat  is  not  practicable, 
there  may  be  placed  over  the  sore  the  following  ointment: 

IJ  Ung.  hydrargyri, 
Ung.  iodi  comp., 
Ung.  belladonnje, 
Ung.   petrolei  carbolat.,   aa   3ii. 

Over  this  is  placed  a  compress,  and  firm  pressure  is  made  by  means  of  a 
spica  bandage. 

After  twenty-four  hours  of  this  treatment,  if  there  is  no  improvement,  and 
particularly  if  the  pain,  swelling,  and  inflammatory  phenomena  are  more  marked, 
time  and  suffering  will  be  saved  the  patient  by  administering  ether,  and  then 
proceeding  at  once  to  excise  the  affected  node  or  nodes,  since  it  is  almost  certain 
in  these  cases  that  suppuration  will  take  place.  All  enlarged  nodes  are  shelled 
out,  and  the  wound  is  thoroughly  cleaned,  and  is  closed  without  drainage.  When 
patients  object  to  this  radical  treatment,' — and  this  will  be  in  the  majority  of 
cases, — an  effort  should  be  made  to  cause  resolution  by  the  injection  of  antiseptic 
solutions  into  the  substance  of  the  inflamed  gland.  The  drug  most  employed 
is  benzoate  of  mercury  in  one  per  cent,  solution.  From  ten  to  fifteen  drops  of 
this  are  driven  directly  into  the  inflammatory  focus.  Antiseptic  compresses 
and  a  pressure  bandage  are  then  applied  over  the  affected  region.  In  place  of 
the  benzoate  of  mercury  a  three  per  cent,  solution  of  carbolic  acid  may  be 
employed,  ten  to  twenty  minims  being  injected.  After  the  injections  there  is  a 
temporary  increase  in  the  amount  of  swelling. 

If  suppuration  occurs  in  spite  of  this  treatment,  or,  when  a  case  first  comes 
under  observation,  if  there  is  fluctuation,  the  abscess-sac  should  be  punctured 
under  antiseptic  precautions,  its  contents  squeezed  out,  and  ten  per  cent,  iodo- 
form glycerin  emulsion  injected  under  moderate  tension.  The  cavity  should 
be  emptied  and  refilled  twice;  as  much  as  will  remain  of  the  third  filling  should 
be  left  in,  and  over  the  seat  of  abscess-formation  should  be  placed  a  large 
absorbent  antiseptic  dressing.  If,  following  this  operation,  there  is  reaccumu- 
lation  of  fluid  in  the  abscess-cavity,  it  should  again  be  evacuated  by  puncture 
and  injected  with  the  iodoform  emulsion.  If  more  than  two  punctures  are 
required,  the  cavities  should  be  freely  incised,  gently  curetted,  packed  with 
sterile  iodoform  gauze,  and  dressed  antiseptically. 

If  when  the  case  comes  under  observation  there  is  a  large  abscess  with  the 
overlying  skin  livid  and  devitalized,  or  already  ulcerated  through,  the  cavity 
should  be  opened  by  a  free  incision  parallel  to  Poupart's  ligament.     Careful 
9 


130  GENITO-URINARY  SURGER^f 

search  should  be  made  for  glands  beginning  to  soften  but  not  yet  completely 
broken  down,  which  should  be  removed  either  by  means  of  blunt  dissection  with 
the  finger,  or  by  careful  cutting  with  the  knife.  The  whole  wound  cavity  should 
be  thoroughly  curetted,  and  should  be  packed  with  sterile  iodoform  gauze. 
Any  sinuses  which  may  form  must  be  followed  to  their  end,  being  freely  slit 
open  to  the  surface.  This  operation  sometimes  results  in  an  enormous  wound, 
but  no  hesitation  should  be  felt  in  making  it,  since  otherwise  ultimate  cure  is 
uncertain. 

When  that  form  of  inflammation  is  encountered  which  is  sometimes  seen 
in  tuberculous  cases  (that  is,  when  node  after  node  enlarges  and  slowly  breaks 
down,  its  capsule  becoming  firmly  adherent  to  the  surrounding  parts  and  the 
whole  forming  a  large  lobulated  tumor)  removal  by  careful  dissection  is  the 
only  means  of  treatment  which  will  be  followed  by  cure.  In  these  cases  the 
nodes  sometimes  contract  adhesions  to  the  femoral  vein,  and  a  number  of 
deaths  have  been  recorded  from  the  wounding  of  this  vessel  in  the  course  of 
an  operation.    Following  the  dissection  the  wound  is  packed  with  iodoform  gauze. 

When  the  bubo  has  ruptured  before  it  has  come  under  observation,  and 
when  it  is  infected  with  the  ordinary  pyogenic  microbes,  in  addition  to  free 
incision  and  curetting  it  is  well  to  paint  the  whole  raw  surface  with  a  solution  of 
tincture  of  iodin,  subsequently  packing  with  iodoform  and  dressing  the  wound 
as  before  described. 

When  a  bubo  becomes  chancroidal  in  type,  the  resultant  sore  should  be 
treated  in  accordance  with  the  principles  governing  the  treatment  of  chancroid. 
Thorough  cauterization  will  usually  be  followed  by  prompt  cure.  If  cauterants 
cannot  be  employed,  applications  of  the  ordinary  antiseptics  are  often  efficacious. 

The  treatment  of  chancroidal  buboes  may  be  summarized  as  follows:  (1) 
Buboes  are  to  be  avoided  by  thorough  frequent  cleansing  of  the  chancroids 
and  by  rest  upon  the  part  of  the  patient.  (2)  They  may  be  aborted  in  their 
earliest  stages  by  active  purgation,  by  rest  in  bed,  and  by  the  application  of 
heat  and  pressure.  If  in  twenty-four  hours  abortive  treatment  is  not  followed 
by  improvement,  no  further  effort  should  be  made  in  this  direction.  (3)  If  the 
bubo  is  steadily  progressing  in  spite  of  appropriate  treatment,  excision  before 
softening  has  occurred  offers  the  quickest  method  of  cure.  (4)  When  this  is 
not  practicable,  injections  of  antiseptics  into  the  substance  of  the  diseased  glands, 
followed  by  pressure  and  rest,  often  bring  about  resolution.  (5)  When  softening 
has  occurred,  but  the  skin  is  not  yet  involved,  evacuation  of  the  contents  of 
the  abscess  through  a  small  puncture,  followed  by  iodoform  injection  or  antiseptic 
irrigation  and  the  application  of  a  pressure  bandage,  favor  resolution.  (6)  If 
after  this  treatment  once  repeated  the  abscess-cavity  again  fills,  or  if  the  abscess 
is  large  and  the  skin  is  already  partly  devitalized,  the  abscess  should  be  opened 
by  free  incision  parallel  with  Poupart's  ligament,  all  enlarged  nodes  should  be 
shelled  out  or  excised,  all  sinuses  should  be  followed  to  their  extreme  limit 
and  opened  freely,  and  the  ulcerating  wound  should  be  packed  with  iodoform 
gauze.  (7)  This  same  treatment  should  be  applied  to  buboes  which  have  already 
opened  spontaneously,  and  should  be  supplemented  by  the  application  of  tincture 
of  iodin  to  the  curetted  surfaces.  (8)  The  tuberculous  type  of  bubo  requires 
excision  of  all  the  enlarged  nodes.  (9)  All  operations  on  chancroidal  buboes 
should  be  conducted  with  scrupulous  regard  to  the  principles  of  asepsis. 


SURGERY  OF  THE  PENIS 


131 


TUMORS  OF  THE  PENIS 

Tumors  of  the  penis  may  be  cystic  or  solid,  benign  or  malignant. 

Under  the  benign  tumors  are  included   the  cysts    (sebaceous,   blood,   and 
mucous),  papilloma,  horny  growths,  angioma, 
fibrolipoma,  and  adenoma.    Except  papilloma, 
these  lesions  are  rare. 

The  malignant  tumors  include  carcinoma 
and  sarcoma,  the  former  being  by  far  the 
commoner.  Carcinoma  and  sarcoma  are 
sometimes  observed  in  infants. 

Cysts,  fibroma,  angioma,  etc.,  are  so 
rarely  observed,  and  when  seen  coincide  so 
completely  with  similar  growths  of  other 
parts  of  the  body,  that  they  require  no  de- 
tailed mention.  Sebaceous  cysts  are  occasion- 
ally seen  in  the  prepuce.  Cysts  from  disten- 
tion of  Tyson's  glands  may  be  multiple,  and 
sometimes  reach  large  size.  Angiomata  have 
caused  troublesome  bladder  reflexes. 

The  treatment  is  the  same  as  that  appro- 
priate to  like  conditions  in  other  parts  of  the 
body,  i.e.,  removal  when  they  are  increasing 
in  size  or  cause  pain  or  interfere  with  func- 
tion. 

Lymphangioma,  or  elephantiasis,  rarely 
involves  the  penis  alone;  usually  the  scrotum 
is  implicated  (Fig.  68).  When  secondary  to 
inflammation  or  removal  of  the  inguinal 
glands  it  may  be  self-limited  and  transitory. 
Operation  may  be  required  (see  p.  295).  The 
filaria  sanguinis  hominis  m.ay  or  may  not  be 
found.  The  diagnosis  is  nearly  always  ren- 
dered easy  by  a  history  of  preceding  inguinal 
adenitis,  or  by  the  associated  thickening  of 
the  skin  of  the  scrotum  and  lower  extremi- 
ties. WTien  the  foreskin  is  primarily  attacked, 
at  least  in  the  early  stages,  it  may  be  difficult. 
and  at  times  even  impossible,  to  decide 
whether  the  overgrowth  is  due  to  infiltration 
consequent  upon  a  chronic  balanoposthitis, 
or  to  elephantiasis.  The  steady  progress  of 
the  infiltration,  in  spite  of  local  cleanliness,  in 
a  short  time  leads  to  a  correct  diagnosis. 

Verrucae  or  Papillomata. — Venereal  warts  appear  as  small  or  large,  discrete 
or  confluent,  moist  or  dry  papillary  overgrowths,  usually  springing  from  the 
coronary  sulcus,  the  posterior  border  of  the  glans  penis,  the  inner  surface  and 


Fig.  68. — Elephantiasis  arabum.  (Oper- 
ated by  Professor  Neill,  University  of 
Pennsylvania.)  (From  Mutter  Museum, 
College  of  Physicians.   Dec.    19,    1874.) 


132 


GENITO-URINARY  SURGERY 


margin  of  the  prepuce,  the  region  of  the  frsenum,  or  the  orifice  of  the  urethra 
(Fig.  69). 

Pathologically  these  outgrowths  are  found  to  be  due  to  hypertrophy  of  the 
papillar>^  and  mucous  layers  of  the  skin.  At  the  same  time  there  is  a  correspond- 
ing development  of  blood-vessels.  On  the  protected  surfaces  they  are  moist,  from 
maceration  of  the  epithelial  covering ;  on  the  skin  surfaces,  as  the  penis,  scrotum, 
or  thigh,  they  are  generally  dry. 

The  cause  of  venereal  warts  can  usually  be  traced  to  irritation  incident  to 
prolonged  contact  with  inflammatory  discharges.  Thus,  in  the  uncleanly,  in 
those  suffering  from  gonorrhoea,  herpes,  chancroid,  or  balanoposthitis,  papillary 
outgrowths  are  b}^  no  means  uncommon.  The  most  important  predisposing  cause 
is  a  redundant  or  phimotic  foreskin.  In  addition  there  seems  to  be  in  certain 
persons  a  constitutional  predisposition  towards  papillary  outgrowths.     Proof 

as  to  the  contagious  nature  of  discharges  from 
venereal  warts  is  still  wanting,  though  there  are 
many  recorded  cases  of  condylomata  developing 
apparently  as  the  result  of  contagion. 

Symptoms. — Condylomata  are  found  most 
often  in  men  between  the  fifteenth  and  the  twenty- 
fifth  year,  and  in  those  who  give  a  history  of  in- 
flammation about  the  genitalia,  either  from  disease 
or  from  redundant  foreskin.  They  appear  as 
markedly  vascular  outgrowths  from  either  the 
skin  or  the  mucous  membrane.  Sometimes  they 
project  like  one  or  more  threads,  or  may  form 
discrete,  small-sized,  tuberous  excrescences,  or  by 
confluence  may  produce  an  outgrowth  resembling 
a  raspberry  or  a  cauliflower.  The  confluent  warts 
often  assume  the  shape  into  which  they  are 
moulded  by  the  pressure  of  the  surrounding  parts; 
thus,  under  the  prepuce,  pressed  beneath  the  fore- 
skin and  the  glans,  they  may  be  flat  and  broad 
like  a  cock's  comb. 
Diagnosis. — Venereal  warts  may  be  confounded  with  the  mucous  patch  or 
condyloma  lata,  and  with  epithelioma. 

The  condyloma  lata  or  mucous  patch  rarely  appears  as  an  isolated  lesion 
of  syphilis;  the  concomitant  signs  of  the  disease  and  a  history  of  the  case  usually 
indicate  the  nature  of  the  affection,  though  it  must  not  be  forgotten  that  syphilis 
may  excite  true  papillary  overgrowth  almost  identical  in  appearance  with  the 
overgrowth  of  condyloma  acuminata. 

Epithelioma  usually  occurs  after  middle  life.  It  ulcprates,  grows  rapidly, 
inv^olves  the  surrounding  tissues  in  a  dense  infiltrate,  and  is  accompanied  by  a 
characteristic  induration  of  the  inguinal  nodes. 

A  wart  found  upon  the  sexual  organs  of  an  old  person,  even  if  characteristic 
in  appearance,  should  always  excite  suspicion,  since  this  benign  neoplasm  is 
comparatively  rare  after  middle  life,  while  malignant  growths  are  by  no  means 
uncommon,  and  in  their  early  period  closely  resemble  the  venereal  wart.     At  the 


Fig.  69. — Venereal  warts. 


SURGERY  OF  THE  PENIS  I33 

time  the  differential  diagnosis  is  most  important,  i.e.,  in  the  beginning,  it  is 
most  difficult.  It  should  be  remembered  that  even  at  this  period  of  the  disease 
the  malignant  growth  infiltrates  the  tissues  from  which  it  springs.  Only  by 
means  of  microscopic  examination  of  sections  from  the  outgrowth  can  a  positive 
opinion  be  given,  since  clinical  experience  shows  that  the  benign  neoplasm  is  at 
times  transformed  into  a  malignant  growth. 

Prognosis. — Venereal  warts,  if  kept  clean,  and  protected  from  mechanical 
irritation,  spontaneously  disappear,  though  predictions  as  to  when  this  result 
will  occur  can  never  be  made  with  safety.  If  utterly  neglected,  they  ulcerate 
and  suppurate,  and  may  often  be  complicated  by  inflammatory  buboes  or  by 
sloughing  and  gangrene.    Exceptionally  they  form  the  starting  point  of  cancer. 

Treatment. — Complete  removal  of  the  papilloma  constitutes  the  only  reliable 
treatment.  Where  the  outgrowths  are  discrete  and  small,  each  is  seized  in  a  pair 
of  rat-tooth  forceps,  drawn  upward,  and  removed,  together  with  the  tissues  of 
its  base,  by  a  snip  of  the  scissors  after  having  had  injected  beneath  its  base  a 
drop  of  a  one  per  cent,  solution  of  eucaine.  If  the  warts  spring  from  the  glans, 
the  little  bleeding  points  left  by  this  cutting  are  touched  with  pure  carbolic 
acid,  and  the  dressing  is  completed  by  dusting  with  iodoform  or  other  powder, 
and,  if  necessary,  applying  a  clean  narrow  gauze  pressure  bandage.  The  wound 
left  by  snipping  warts  from  the  prepuce  is  at  once  closed  by  suture  without 
cauterization.  When  the  neoplasm  has  a  large  base,  the  whole  outgrowth  may 
be  shaved  off  level  with  the  surrounding  surface  by  means  of  a  sharp,  flat  knife. 
The  wound  left  by  this  incision  should  be  thoroughly  curetted,  and  then  should 
be  cauterized  with  carbolic  or  nitric  acid  and  dressed  with  iodoform  or  with  a 
powder  made  of  calomel  and  zinc  oxide,  equal  parts  of  each.  General  anaesthesia 
is  required  for  this  operation.  Only  spouting  vessels  should  be  ligated,  the  free 
primary  oozing  being  readily  controlled  by  the  application  of  adrenahn  chloride 
solution  (1  to  1000). 

At  the  time  this  operation  is  performed  an  effort  should  be  made  to  remove 
the  exciting  cause  of  the  lesion.  Thus,  phimotic  patients  should  be  circumcised, 
urethral  discharges  should  be  prevented  from  coming  in  contact  with  the  external 
parts,  etc. 

When  operation  is  refused,  warts  may  be  removed  by  nitric  acid.  The 
surrounding  surfaces  should  be  protected  by  the  application  of  cosmoline;  the 
acid  is  well  rubbed  into  the  wart  and  a  boric  ointment  dressing  is  applied. 
The  application  is  repeated  every  second  or  third  day  until  the  papillary  layer  of 
the  skin  is  destroyed  at  the  point  of  outgrowth. 

Chromic  acid  is  an  excellent  application,  but  is  open  to  the  objection  that 
occasionally  it  gives  rise  to  general  toxic  symptoms.  _  Fatal  cases  have  been 
reported.  It  is  usually  employed  either  pure  or  in  a  ten  per  cent,  solution, 
brushed  over  the  outgrowth  once  daily. 

Certain  non-cauterant  remedies  are  advised,  and  at  times  give  good  results, 
possibly  because  of  the  spontaneous  tendency  towards  healing  exhibited  by  the 
condylomata.    Among  these  may  be  mentioned  the  following: 

Acidi  salicylici,  oi 
Acidi  acetici,  f.5i 
M.  S. — Apply  with  a  brush  once  daily. 


134 


GENITO-URINARY  SURGERY 


f 


The  effect  of  irritants  not  strong  enough  to  act  as  cauterants  is  to  stimulate 
the  papillary  outgrowths. 

High-frequency  desiccation  or  fulguration  by  the  Oudin  current  is  an  efficient 
method  for  the  destruction  of  these  papillomata,  a  single  treatment  sometimes 
being  sufficient  for  the  complete  removal  of  the  condylomata.  Before  the 
application  of  the  spark,  the  warts  should  be  treated  for  ten  minutes  with  a 
fledget  of  cotton  saturated  with  ten  per  cent,  cocaine  solution. 

Horny  Growths  of  the  Penis. — In  the  few  reported  cases  of  this  affection 
the  growth  has  sprung  from  the  surface  of  the  glans  penis  of  old  men.  It  is 
an  extremely  rare  manifestation  of  perverted  epidermic  h3T3ertrophy.     It  .is 

easily  recognized,  and  its  main 
pathological  importance  lies  in  the 
fact  that  it  is  at  times  the  fore- 
runner of  cancer.  The  appropri- 
ate treatment  is  the  thorough  re- 
moval of  the  horn,  together  with 
the  base  from  which  it  grows. 
When  the  patient  is  advanced  in 
years  and  there  is  no  indication  of 
epitheliomatous  degeneration,  sur- 
gical operation  is  not  indicated. 

Malignant  Disease.  —  With 
the  exception  of  epithelioma,  ma- 
lignant disease  of  the  penis  is  ex- 
tremely rare. 

A  few  cases  of  medullary  can- 
cer have  been  described.  These 
develop  about  the  period  of  pu- 
berty, and  are  apt  to  be  conse- 
quent on  trauma.  They  form 
rapidly  growing,  lobulated,  painful 
tumors.  The  lobules  may  be  so 
soft  as  to  suggest  the  formation 
of  a  cyst.  They  are  usually  the 
phenomena  of  subacute  inflamma- 
tion, and  the  lymphatic  nodes  of  the  groin  are  quickly  involved.  Amputation 
carried  wide  of  the  disease  is  the  only  treatment,  and  even  if  this  procedure 
be  adopted  early,  the  ultimate  outlook  is  extremely  unfavorable.  Epithelioma 
or  cancer  commonly  appears  on  either  the  glans  or  the  prepuce.  It  may  assume 
the  superficial  or  the  infiltrating  form  (Fig.  70).  It  usually  develops  after 
middle  age,  and  sometimes  grows  from  the  seat  of  a  former  chancre. 

Symptoms. — Epithelioma  generally  appears  first  in  the  form  of  a  wart,  which 
becomes  excoriated,  ulcerated,  and  shortly  indurated.  The  disease,  beginning 
as  a  small  ulcerative  vegetation,  gradually  extends  until  a  large  portion  of  the 
prepuce  and  glans  is  involved  (Plate  VI,  B,  and  Fig.  71).  The  ulceration  has 
a  hard  base  and  is  irregularly  excavated.    Together  with  the  deep  ulcers  there 


Fig.  70. — Epithelioma.    (Demarquay.) 


SURGERY  OF  THE  PENIS 


135 


Fic.   71. — Epithelioma,  ulcerating  form. 


Fig    72  — Epithelioma,  vegetating  form. 


136 


GENITO-URINARY  SURGERY 


are  often  cauliflower-like  outgrowths  (Figs.  72  and  73).  The  surrounding 
skin  is  infiltrated,  cedematous,  nodular,  elevated,  and  purplish  in  color.  The 
glans  is  greatly  swollen,  irregular  in  outline,  and  lobulated. 

As  the  disease  extends  backward  the  cavernous  bodies  become  indurated 
and  the  overlying  skin,  at  first  slightly  adherent,  is  involved  in  the  disease. 


Fig.  73. — Carcinoma  of  penis,  with  early  lymphatic  involvement.     (No  recurrence  g  years  after 

operation.) 


Fig.   74. — Epithelioma  with  glandular  involvement. 


Finally  the  lymphatic  nodes  of  the  groin  become  infiltrated  and  ulcerated,  and 
discharge  fetid,  blood-stained  pus  (Fig.  74). 

Etiology. — The  presence  of  a  redundant  or  phimotic  foreskin,  accumulations 
of  smegma,  subpreputial  calculi,  chronic  balanoposthitis,  specific  or  nonspecific 
ulcerations,  indeed,  any  source  of  local  irritation,  may  act  as  a  predisposing 
cause  for  the  development  of  epithelioma. 


SURGERY  OF  THE  PENIS 


137 


Diagnosis. — This  is  difficult  only  in  the  early  stages  of  the  disease. 

When  without  obvious  cause  a  warty  growth  develops  on  the  glans  or  the 
foreskin  in  a  person  past  middle  life,  this  lesion  should  be  carefully  watched. 
Induration  about  the  base  (Fig.  75)  or  ulceration  of  the  excrescence  would 
justify  the  diagnosis  of  epithelioma,  and  would  indicate  a  prompt  removal. 

Syphilis  of  the  penis  may  be  mistaken  for  epithelioma,  but  may  be  recognized 
by  the  characteristics  described  under  this  subject. 

Prognosis. — The  prognosis  of  epithelioma  is  grave  unless  operation  is  under- 
taken in  its  very  earliest  stages.  The  course  of  the  affection  varies  greatly  in 
different  cases.  Some  patients  perish  in  two  months,  others  survive  for  many 
years.  When  the  inguinal  nodes  are  involved  there  is  but  slight  chance  of 
ultimate  recovery. 

Treatment. — The  only  treatment  to  be  considered  in  these  cases  is  entire 
removal  of  the  diseased  part.    When  the  disease  has  not  developed  further  than 


Fig.     75. — Longitudinal    section,    showing    infiltration    of    a    carcinoma.   (Laboratory 
of    Surgical     Pathology,     University   of   Pennsylvania.) 

slight  ulceration  of  an  indurated  papule,  total  excision  of  the  involved  area,, 
with  subsequent  cauterization  of  the  excision  wound  by  means  of  caustic  potash, 
may  suffice. 

When  epithelioma  is  fairly  developed,  amputation  carried  wide  of  the  disease 
is  the  only  resource.  The  inguinal  lymphatic  nodes  should  be  removed  at  the 
same  time,  even  though  not  enlarged. 

Partial  Amputation  of  the  Penis. — This  operation  is  indicated  when  the 
ulceration  or  infiltration  lies  an  inch  or  more  in  front  of  the  penoscrotal  junction. 
The  ulcerating  mass  having  been  cauterized  with  pure  carbolic  acid  and  occluded 
by  a  dressing  wet  in  1  to  1000  corrosive  chloride,  and  the  inguinal  regions 
having  been  thoroughly  cleansed  as  for  any  surgical  operation,  an  incision  is 
carried  from  the  middle  of  Poupart's  ligament  to  the  dorsum  of  the  penis,  thence 
down  the  middle  of  this  organ  to  the  seat  of  amputation.  The  superficial  layer 
of  fat  containing  the  nodes  is  then  dissected  up  from  each  inguinal  region  and 
is  stripped  inward,  including  the  lymphatic  vessels  of  the  penis.  This  mass  of 
tissue,  made  up  of  two  wings,  is  carried  downward  and  the  Y-shaped  incision  is 


138  GENITO-URINARY  SURGERY 

closed  by  suture.  Two  inches  or  more  behind  the  epithelioma  a  stout  acupressure 
needle  is  thrust  through  the  corpora  cavernosa  from  side  to  side,  and  behind 
this  a  medium-sized  drainage-tube  is  wound  two  or  three  times  around  the 
penis  and  kept  in  place  by  catch  forceps  or  by  knotting.  By  a  circular  sweep 
of  the  knife  the  skin  of  the  penis  is  divided  at  the  proposed  seat  of  amputation, 
which  should  be  at  least  one  inch  behind  the  farthest  backward  extension  of 
the  malignant  infiltration.  Half  an  inch  in  front  of  this  the  spongy  body  of 
the  urethra  is  cut  across  and  dissected  back  to  the  level  of  the  skin  incision. 
The  corpora  cavernosa  are  then  cut  through  on  a  level  with  the  first  incision, 
the  rubber-ligature  is  removed,  the  bleeding  vessels  are  secured  by  means  of 
fine-pointed  haemostatic  forceps  and  by  catgut  ligatures,  and  the  acupressure 
pin  is  taken  out.  Sutures  are  then  passed,  drawing  together  the  cut  edges  of 
the  fibrous  sheaths  of  the  cavernous  bodies,  .thus  completely  covering  in  the 
vascular  erectile  tissue,  and  both  protecting  it  from  subsequent  infiltration  and 
infection  by  the  urine  and  immediately  checking  oozing.  The  urethra  is  split 
on  its  floor  back  to  the  level  of  the  surface  of  the  divided  cavernous  bodies. 
The  borders  of  this  incision,  together  with  the  divided  urethral  end,  are  sutured 
to  the  skin.  The  latter  is  then  stitched  so  as  to  cover  in  the  cavernous  bodies. 
The  line  of  suture  is  dusted  with  iodoform  and  is  dressed  with  iodoform  gauze. 
The  dressing  is  held  in  place  by  a  T-bandage.  Continuous  catheterization  may 
be  employed;  it  is  better,  however,  to  let  the  patient  micturate  when  desire 
prompts,  removing  the  dressing  to  allow  of  this  and  irrigating  the  wound  imme- 
diately afterwards  with  corrosive  chloride  solution  (1  to  4000). 

Recurrence  in  the  stump  after  partial  amputation  is  rare,  death  usually 
resulting  from  lymphatic  involvement.  During  the  operation,  with  the  help  of  a 
freezing  microtome,  the  cross-section  should  be  carefully  examined  for  evidences 
of  malignant  infiltration,  which  if  found  would  indicate  a  more  complete  removal. 
The  stump  following  the  partial  operation  enables  the  patient  to  urinate  normally 
and  at  times  to  satisfactorily  accompHsh  the  sexual  act. 

Extirpation  of  the  Entire  Penis. — This  procedure  is  indicated  when  the 
disease  is  so  far  advanced  that  partial  excision  can  no  longer  be  considered. 
Treves  describes  the  operation  as  follows: 

The  patient  is  placed  in  the  lithotomy  position,  and  the  skin  of  the  scrotum 
is  incised  along  the  whole  length  of  the  raphe.  With  the  finger  and  the  handle 
of  the  scalpel  the  halves  of  the  scrotum  are  separated  down  to  the  corpus 
spongiosum.  A  full-sized  metal  catheter  is  passed  as  far  as  the  triangular  liga- 
ment, and  a  knife  is  inserted  transversely  between  the  corpora  cavernosa  and 
the  corpus  spongiosum.  The  catheter  is  withdrawn,  the  urethra  is  cut  across, 
and  its  deep  end  is  detached  from  the  penis  back  to  the  triangular  ligament. 
An  incision  is  made  around  the  root  of  the  penis  continuous  with  that  in  the 
median  line.  The  suspensory  ligament  is  divided  and  the  penis  is  separated, 
except  at  the  attachment  to  the  crus.  The  knife  is  then  laid  aside,  and  with 
a  stout  periosteal  elevator  or  rugine  each  crus  is  detached  from  the  pubic  arch. 
The  two  arteries  of  the  corpora  cavernosa  and  the  two  dorsal  arteries  require 
ligature.  The  urethra  and  corpus  spongiosum  are  split  up  for  about  half  an  inch, 
and  the  edges  of  the  cut  are  stitched  to  the  back  part  of  the  incision  in  the 
scrotum.  The  scrotal  incision  is  closed  by  sutures,  and  if  drainage  is  used 
the  tube  is  so  placed  in  the  deep  part  of  the  wound  that  its  end  can  be  brought 
out  in  front  and  behind.    A  catheter  is  usually  retained  in  the  urethra. 


CHAPTER  IX 

SURGERY  OF  THE  URETHRA 

(Except  Urethritis  and  Stricture) 

THE  ANATOMY  OF  THE  URETHRA 

The  urethra,  serving  the  double  purpose  of  a  carrier  for  the  urine  and  for 
the  semen,  is  a  tubular  passage  about  eight  inches  in  length,  of  somewhat 
changing  calibre  in  various  parts  of  its  course.  Originating  from  the  bladder, 
it  passes  through  the  upper  part  of  the  central  portion  of  the  prostate  gland, 
pierces  the  anterior  and  posterior  layers  of  the  triangular  ligament  about  one 
inch  below  the  lower  border  of  the  pubic  symphysis,  and  then,  surrounded  by 
the  corpus  spongiosum,  passes  on  through  the  penis  to  the  meatus   (Fig.  76). 

The  prostatic  portion  of  the  urethra  is  about  an  inch  and  a  quarter  long, 
and  is  the  widest  and  most  dilatable  part  of  the  canal;  the  membranous  portion 
is  about  three-quarters  of  an  inch  long,  and  is  the  narrowest,  least  dilatable 
part  of  the  urethra,  except  the  meatus.  The  spongy  or  penile  portion  of  the 
canal  is  about  six  inches  in  length. 

The  meatus  is  the  narrowest  part  of  the  urethra.  Immediately  behind  this 
opening  the  passage  widens  somewhat,  forming  the  fossa  navicularis.  Passing 
backward,  the  urethra  becomes  slightly  narrower,  and,  exhibiting  a  nearly  uni- 
form diameter,  traverses  the  spongy  body  till  it  reaches  the  bulb,  or  posterior 
portion  of  this  body,  where  it  again  dilates.  This  dilatation  narrows  abruptly 
at  the  anterior  layer  of  the  triangular  ligament,  the  membranous  urethra  being 
of  small  but  uniform  calibre.  After  passing  through  the  posterior  layer  of  the 
triangular  ligament  the  urethra  again  widens  out,  reaching  its  greatest  diameter 
at  the  position  of  the  caput  gallinaginis.  Before  passing  into  the  bladder  there 
is  a  slight  narrowing,  noticeable  only  when  the  latter  viscus  is  empty. 

There  are,  then,  three  regions  of  physiological  dilatation.  These  are  located 
in  the  prostate  gland,  at  the  bulb,  and  behind  the  meatus.  The  natural  posi- 
tions of  physiological  narrowing  are  at  the  micatus  and  the  membranous  por- 
tion of  the  canal. 

The  mucous  membrane  is  continuous  with  the  bladder  internally  and  with 
the  integument  of  the  glans  penis  externally.  It  is  prolonged  into  the  ducts 
of  all  the  glands  which  open  into  the  urethra.  The  epithelial  lining  is  fiat 
and  laminated  near  the  meatus;  in  other  portions  of  the  tube  it  is  columnar. 

The  submucous  tissue  is  made  up  of  fibrous  and  elastic  tissue,  together 
with  unstriped  muscular  fibres.  These  latter  are  arranged  in  two  layers,  one 
passing  longitudinally,  the  other  circularly.  This  muscular  layer  is  most  marked 
in  the  prostatic  and  membranous  portions  of  the  urethra;  passing  forward, 
it  becomes  thinner,  till  in  the  anterior  part  of  the  spongy  urethra  it  is  replaced 
in  a  great  measure  by  fibrous  tissue. 

On  the  mucous  membrane  of  the  urethra  may  be  seen  the  openings  of 
many  glands  and  follicles.    These  are  situated  in  the  submucous  tissue.     The 

139 


140 


GENITO-URIXARY  SURGERY 


glands,  called  the  glands  of  Littre,  vary  greatly  in  size,  and  are  most  abundant 
in  the  spongy  portion  of  the  canal  and  about  the  meatus.  Their  orifices  are 
directed  forward.  The  largest  of  the  follicles,  called  the  lacuna  magna,  is 
situated  in  the  upper  wall  of  the  fossa  navicularis,  and  is  one  and  one-half 
inches  from  the  meatus. 


Externlal  iliac 
artery 

External  iliac 
vein 

Deep  epigastric 
artery 
Spermatic  vessels 

Internal  abdominal 
ring 


Obliterated 
hypogastric  artery 

Urachus 


Suspensory 
ligament  of  penis 

Internal  urethral  orifice^ 

Fatty  tissue- 
containing  veins 


Pectinate  septum — }-*=-  <\ 
Spongy  urethra-      ^  *^ 


Navicular  fossa 


•Ureter,  entering 
bladder 


Seminal  vesicle 


Ejaculatorj'  duct 

Prostatic  urethra 
and  utricle 


Membranous  urethra 


■Bulb  of  cavernous  body 


Bulbous  urethra 


Scrotum 


Fig.   76. — Dissection  of  sagittally  cut  pelvis,  showing  relations  of  organs  after  fixation  by  formalin  injec- 
tion.    (Piersol's  Anatomy.) 

The  spongy  portion  of  the  urethra,  so  named  because  it  is  surrounded  by 
the  erectile  tissue  of  the  corpus  spongiosum,  extends  from  the  meatus  to  the 
anterior  layer  of  the  triangular  ligament.  It  is  further  subdivided  into  a  pen- 
dulous and  a  bulbous  portion.  The  pendulous  portion  extends  from  the  meatus 
to  the  dilatation  enclosed  by  the  bulb  (about  four  and  one-half  inches  in  length). 
The  bulbous  portion  or  dilatation  (about  an  inch  to  an  inch  and  a  half  long) 


SURGERY  OF  THE  URETHRA 


141 


is  abundantly  supplied  with  mucous  glands  and- follicles;  into  it  also  pass  the 
ducts  of  Cowper's  glands.  In  direction  the  spongy  urethra  first  passes  upward, 
then  curves  downward. 

The  membranous  portion  of  the  urethra,  beginning  at  the  prostate  gland  and 


Fossa  navicularis 
Glans 


Glands  of  Littre 


Duct  of  Cowper's  gland 

Cowper's  gland 

Membranous  urethra 

Prostatic  ducts 

Prostate 


Urethral  orifice 


Prepuce 


— Corpus  cavernosum 


Crypts  of  Morgagni 


•Frenulae  cristae 

Ejaculatory  duct 
iVerumontanum 
Sinus  pocularis 

Urethral  crest 


Interureteric  ridge 


Ureter 


Fig.  77. — Diagrammatic  view  of  horizontal  section  of  bladder  and  urethra. 

ending  at  the  bulb,  is  separated  from  the  pubic  symphysis  by  muscular  fibre 
and  by  the  dorsal  vessels  and  nerves  of  the  penis;  below  it  lie  Cowper's  glands. 
Its  upper  surface  is  concave,  and  is  about  one-quarter  of  an  inch  longer  than 
the  lower  surface.     The  perineum  separates  the  lower  surface  of  the  mem- 


142  GENITO-URINARY  SURGERY 

branous  urethra  from  the  rectum.  In  this  portion  of  the  urethra  the  erectile 
tissue  is  but  slightly  developed;  in  place  of  it  there  is  a  complicated  investment 
of  muscular  fibres.  First  there  is  a  layer  of  unstriped  fibres  passing  circularly 
and  longitudinally.  External  to  this  there  is  an  investment  of  voluntary  muscu- 
lar fibres  completely  surrounding  the  urethra.  This  muscular  sheath  is  named 
the  compressor  urethrse. 

The  prostatic  urethra  is  spindle-shaped, — that  is,  it  is  widest  at  its  middle. 
On  the  floor  of  the  canal  the  mucous  membrane  is  projected  in  the  form  of  a 
longitudinal  ridge,  called  the  verumontanum,  or  caput  gallinaginis  (Fig.  77).  On 
each  side  of  this  ridge  lies  a  depression,  called  the  prostatic  sinus,  into  which 
open  the  orifices  of  the  prostatic  ducts.  At  the  summit  of  the  verumontanum 
is  the  sinus  pocularis,  a  blind  pouph  running  upward  and  backward  beneath 
the  middle  portion  of  the  prostate  gland.  At  or  just  within  the  margin  of  the 
sinus  pocularis  are  the  slit-like  openings  of  the  ejaculatory  ducts. 

At  the  point  where  the  prostatic  urethra  enters  the  bladder  it  is  surrounded 
by  a  muscle  made  up  of  unstriped  fibres,  called  the  internal  vesical  sphincter; 
anterior  to  this  a  double  layer  of  unstriped  muscular  fibres  and  the  glandular 
structure  of  the  prostate  surround  the  urethra.  At  the  apex  of  the  prostate 
there  is  a  sphincter  made  up  of  both  voluntary  and  involuntary  muscular 
fibres,  called  the  external  vesical  sphincter;  it  is  more  powerful  than  the  internal 
sphincter.  Urine  is  retained  in  the  bladder  by  the  tonic  contraction  of  the 
muscular  apparatus  of  the  membranous  and  the  prostatic  urethra  (see  p.  14). 

The  compressor  urethrse  muscle  is  readily  excited  to  reflex  spasm.  Ordi- 
narily, on  the  passage  of  instruments,  a  moderate  degree  of  resistance  can  be 
detected,  due  to  the  contraction  of  this  muscle.  In  irritable  conditions  of  the 
mucous  membrane  there  may  be  excited  a  spasm  so  violent  that  it  will  be 
impossible  to  introduce  a  soft  instrument.  Such  a  spasm  may  also  be  excited 
by  irritation  of  the  prostatic  urethra,  either  from  distention  of  the  bladder  or 
from  any  other  cause.  Thus,  it  is  often  found  extremely  difficult  to  evacuate 
the  bladder  when  the  desire  to  urinate  has  been  resisted  for  many  hours;  and 
acute  inflammation  of  the  posterior  urethra  not  infrequently  requires  the  use 
of  catheters  to  overcome  the  tight  muscular  contraction  of  the  compressor 
urethrse  which  prevents  micturition.  Not  only  the  introduction  of  sounds,  but 
even  the  injection  of  bland  liquids,  may  cause  contraction  of  the  compressor 
urethree  muscle,  and  hence  prevent  such  injection  from  reaching  the  mem- 
branous or  the  prostatic  urethra.  Any  inflammation  in  these  portions  of  the 
urethra  may  also  cause  the  tonic  contraction  of  the  sphincter  muscles  to  be 
accentuated.  Because  of  the  greater  power  of  the  external  sphincter,  accentuated 
in  diseased  conditions  by  this  tendency  to  spasmodic  contraction,  pus  formed 
in  the  posterior  urethra  tends  to  flow  back  into  the  bladder,  not  forward  to 
the  meatus,  while  secretions  formed  in  the  anterior  urethra  never  make  their 
way  backward  past  this  point. 

There  seem,  then,  to  be  good  grounds,  both  from  a  physiological  and  from 
a  clinical  standpoint,  for  dividing  the  urethra  into  an  anterior  erectile  part 
and  a  posterior  muscular  part. 


SURGERY  OF  THE  URETHRA  143 

MALFORMATIONS  OF  THE  URETHRA 

The  urethra  may  be  absent,  obliterated,  congenitally  strictured,  sacculated, 
or  dencient  as  to  its  floor  or  its  roof.  Of  these  anomalies  deficiency  of  the  floor 
and  of  the  roof,  entitled  hypospadia  and  epispadia,  are  most  common. 

Absence  of  the  urethra  is  a  malformation  usually  fatal  to  the  child  before 
birth,  since  the  distended  bladder  by  pressing  on  the  umbilical  arteries  interferes 
with  the  foetal  circulation.  Exceptionally  the  child  is  born  ahve  with  a  greatly 
dilated  bladder,  in  which  case  the  urine  may  escape  through  a  patent  urachus, 
or  by  way  of  the  rectum  or  perineum,  fistulae  being  formed;  or  operation  by 
suprapubic  or  perineal  puncture  may  give  relief. 

Treatment. — The  proper  treatment  for  absent  urethra  would  be  the  forma- 
tion of  a  perineal  fistula,  the  position  of  the  base  of  the  bladder  previously 
having  been  determined  by  digital  examination  through  the  rectum. 

Atresia  or  obstruction  of  the  urethra,  usually  at  one  point,  may  occur  at  any 
portion  of  the  canal,  but  is  commonly  observed  at  or  near  the  meatus.  The 
occlusion  may  be  caused  by  a  thin,  easily  pierced  membrane,  the  variety  ordi- 
narily seen  near  the  meatus  or  in  some  portion  of  the  anterior  urethra;  or  the 
urethra  itself  may  be  converted  into  a  fibrous  cord,  a  form  rarely  observed, 
except  in  or  near  the  membranous  portion  of  the  canal.  In  these  cases  fistulae 
often  form,  giving  spontaneous  relief.  Frequently,  however,  there  is  retention 
of  urine,  with  all  its  disastrous  effects  upon  the  bladder  and  kidneys  and  upon 
the  system  at  large.  As  in  the  case  of  absent  urethra,  the  condition  usually 
causes  the  death  of  the  fcetus. 

The  diagnosis  is  founded  upon  the  failure  of  the  child  to  urinate,  and  the 
presence  of  a  distended  bladder. 

Treatment . — The  treatment,  when  the  obstruction  is  at  or  near  the  meatus, 
consists  in  opening  the  obstructed  portion  of  the  urethra  by  means  of  a  trocar 
and  cannula,  a  tenotome,  or  a  small  sound.  When  it  is  placed  deeper  it  would 
seem  advisable  to  pass  a  sound  down  to  its  anterior  face  and  make  an  attempt 
by  gentle  pressure  exerted  in  the  proper  direction  to  pass  through  it.  Having 
succeeded  in  introducing  an  instrument  and  evacuating  the  urine  (not  all  at 
one  sitting,  in  case  of  great  bladder  distention),  the  sound  is  passed  through  the 
seat  of  obstruction  at  intervals  of  three  days  for  several  weeks. 

When  instruments  cannot  be  introduced,  the  membranous  and  prostatic  por- 
tions of  the  urethra  should  be  opened  by  external  perineal  urethrotomy,  and  the 
posterior  limit  of  the  obstruction  determined  by  passing  an  instrument  from 
behind  forward;  or  if  the  occlusion  extends  well  back  into  the  membranous 
urethra  the  same  result  may  be  accomplished  more  readily  by  performing  supra- 
pubic cystotomy.  The  position  and  the  extent  of  the  urethral  obstruction 
having  been  exactly  determined  by  one  instrument  passed  from  the  meatus 
backward,  and  by  another  passed  from  the  membranous  urethra  or  the  bladder 
forward,  the  urethra  may  be  rendered  pervious  either  by  instruments  cutting 
from  within,  a  long  knife  passed  through  an  endoscopic  tube,  for  instance,  or 
by  an  external  urethrotomy,  followed  by  plastic  operation.  Unless  the  obstruc- 
tion be  limited  to  a  thin  membrane,  external  operation  will  be  required.  An 
attempt  may  be  made  to  repair  the  defect  in  the  urethral  lining  by  transplanting 


144  GENITO-URINARY  SURGERY 

mucous  membrane  from  the  cheek.  This  is  held  in  place  by  a  few  catgut  sutures 
and  the  permanent  catheter,  the  skin  opening  being  closed  by  suture.  The 
catheter  is  left  in  place  six  days.  Regular  dilatation  is  necessary  in  the  after- 
treatment. 

Congenital  strictures,  if  the  usual  narrowing  at  or  just  behind  the  meatus 
be  excepted,  are  extremely  rare.  If  present,  they  are  denoted  by  slow  dribbling 
urination,  with  increased  frequency,  dilatation  of  the  bladder,  and  colicky  pains. 
Such  strictures  should  be  treated  by  gradual  dilatation;  this  failing,  urethrotomy 
is  indicated. 

Very  exceptionally  narrowing  of  the  meatus  becomes  so  extreme  that  the 
act  of  micturition  is  seriously  interfered  with.  There  is  usually  an  associated 
phimosis,  which  hides  the  real  seat  of  obstruction.  Meatotomy  should  be  per- 
formed immediately,  the  meatus  being  kept  patulous  by  the  regular  passage  of 
bougies  till  healing  is  complete. 

Valvular  folds  have  been  found  post-mortem  in  the  prostatic  urethra,  with 
characteristic  changes  of  bladder,  ureters,  and  kidneys,  showing  that  they  had 
occasioned  fatal  obstruction.  Such  folds  are  also  found  about  the  junction  of 
the  penile  and  the  glandular  urethra. 

The  diagnosis  is  difficult,  and  is  founded  on  slow,  difficult,  frequent  urination, 
bladder  distention,  and  colicky  pains  associated  with  a  urethra  which  readily 
admits  a  small  sound. 

The  urethroscopic  tube  (No.  12  to  14  F.)  might  render  possible  both  a 
diagnosis  and  treatrAent  by  cutting  in  the  case  of  prostatic  valves.  The  bulbous 
bougies  should  find  anterior  valves;  these  are  readily  divided  by  a  tenotome. 

Urethral  pouches  or  diverticula  may  sometimes  reach  large  size.  They 
develop  from  the  floor  of  the  urethra,  and  in  the  cases  described  were  found 
just  behind  the  glans.  They  were  not  associated  with  stricture,  but  seemed 
to  be  dependent  for  their  formation  on  absence  of  the  erectile  tissue,  leaving  a 
thin  urethral  wall  which  gradually  dilated.  These  congenital  pouches  are 
associated  with  incontinence  of  urine.  They  become  distended  with  each  act  of 
micturition,  and  there  is  subsequent  dribbling  from  the  slow  leakage  of  the 
urine  contained. 

Diagnosis. — A  diagnosis  is  readily  made  from  the  distention  observed  during 
the  act  of  urination  and  from  the  absence  of  inflammatory  reaction. 

Treatment. — The  treatment  consists  in  removal  of  the  redundant  walls  of 
the  pouch  and  suture  of  mucous  membrane  and  skin  so  that  the  calibre  of  the 
resulting  urethra  at  the  point  of  operation  shall  be  about  normal. 

As  an  unusual  anomaly  the  urethra,  on  inspecting  the  glans,  seems  to  be 
double  or  multiple.  Exploration  of  these  openings  will  show  one  or  more  blind 
pouches,  the  urethra  opening  by  a  single  orifice.  Or  in  case  there  is  a  second 
channel  passing  parallel  with  the  urethra,  this  may  be  a  continuation  of  the 
ejaculatory  ducts. 

HYPOSPADIA 

This  defect  depends  upon  a  congenital  deficiency  of  the  floor  of  the  urethra, 
which  channel,  instead  of  being  continued  to  the  glandular  meatus,  opens  at 
some  point  on  the  lower  surface  of  the  penis.    The  deformity  is  fairly  comm.on. 


SURGERY  OF  THE  URETHRA 


145 


being  counted  by  Bouisson  once  in  three  hundred  males.  Duplay  describes  two 
chief  forms  of  hypospadia:  (1)  that  in  which  the  urethra  is  absent  in  front 
of  the  abnormal  opening,  this  being  the  common  form,  and  (2)  that  in  which 
the  urethra  exists  in  front  of  the  opening,  an  extremely  rare  form. 


In  regard  to  the  position  of  the  opening,  hypospadia  is  classed  (see  Fig.  78) 
as  (1)  balanic,  or  glandular,  the  urethra  terminating  at  the  base  of  the  glans; 
(2)  penile,  the  urethra  terminating  at  a  point  between  the  glans  and  the  peno- 
10 


146 


GENITO-URINARY  SURGERY 


scrotal  junction;   (3)  perineal,  including  under  this  heading  the  perineo-scrotal 
forms,  where  the  urethra  terminates  in  the  scrotal  cleft. 

Cause. — The  cause  of  hypospadia  is  obviously  an  arrest  of  development. 
The  prostatic  and  membranous  portions  of  the  urethra,  the  penile  portion,  and 
the  glandular  portion  are  each  developed  separately.  The  anterior  urethra 
represents,  in  the  early  part  of  its  development,  simply  a  grooye,  which  as  the 
foetus  grows  is  closed  from  behind  forward.  Failure  to  close  any  portion  of 
this  groove,  or  failure  of  any  of  the  three  separately  formed  portions  of  the 
urethra  to  unite,  occasions  hypospadia.  Kaufmann  attributes  hypospadia  to 
obstruction  of  the  urethra  persisting  after  urine  has  been  secreted  by  the  kidneys, 
in  consequence  of  retention  the  urethra  rupturing  behind  the  seat  of  obstruction. 
Balanic  or  glandular  hypospadia  is  characterized  by  a  rather  broad  glans. 


Fig.  79.^Peno-scrotal  hypospadia. 

curved  somewhat  downward,  and  covered  on  its  dorsal  surface  by  a  thickened 
hood,  the  malformed  prepuce.  The  fraenum  is  absent,  and  the  urethra  ter- 
minates usually  in  a  very  small  opening  at  the  base  of  the  glans,  being  con- 
tinued forward  by  a  narrow  groove,  representing  the  upper  wall  of  the  navicular 
fossa.  A  normally  placed  meatus  is  often  found,  but  this  is  simply  a  blind 
pouch.  The  cavernous  bodies  are  well  formed.  Other  deformities  occasionally 
complicate  balanic  hypospadia;  thus,  the  penis  may  be  twisted,  the  cavernous 
bodies  may  be  stunted  or  absent,  the  testicles  may  be  undescended,  or  the  penis 
may  be  adherent. 

Penile  Hypospadia. — The  penis  in  these  cases  (Fig.  79)  is  often  curved 
downward,  the  cavernous  bodies  are  sometimes  poorly  developed,  and  nearly 
always  the  prepuce  is  redundant.     Associated  deformities  are  more  frequently 


SURGERY  OF  THE  URETHRA 


147 


encountered  in  this  class  of  cases  when  hypospadic  openings  are  placed  at  or 
near  the  penoscrotal  angle.  Rarely  the  meatus  and  some  portion  of  the  urethra 
back  of  this  may  be  preserved,  terminating  in  a  blind  pouch;  or  the  urethra 
may  continue  anterior  to  the  hypospadic  opening,  ending  in  a  cul-de-sac  before 
it  reaches  the  meatus;  or  the  urethra  may  be  continuous  to  the  meatus,  hypo- 
spadia then  simply  representing  congenital  fistula.  The  scrotum  is  not  cleft  in 
penile  hypospadia. 

Perineal  hypospadia  represents  the  form  characteristic  of  the  most  marked 
interference  with  development.  The  scrotum  is  divided  by  a  deep  cleft  into 
two  lateral  halves  (Fig.  80),  in  each  of  which  there  may  be  placed  a  normal 
testicle,  though  usually  these  organs  are  only  partially  developed,  and  frequently 


Fig.   80. — Hypospadia     resembling  hermaphroditism.      (From   Mutter   Mus- 
eum, College  of  Physicians.) 

have  not  descended.  In  this  case  the  scrotal  flaps  closely  resemble  the  labia 
majora.  The  penis  is  stunted,  except  in  its  glandular  portion,  and  is  curved 
downward  and  backward  towards  the  scrotal  cleft.  On  raising  it  there  is  seen  a 
funnel-shaped  depression,  in  the  deepest  part  of  which  the  urethra  opens  by  a 
vertical  slit,  provided  at  either  side  with  a  muco-cutaneous  fold,  suggesting 
the  arrangement  of  the  labia  minora.  These  folds  pass  forward  along  the 
under  surface  of  the  penis  and  the  glans,  constituting  either  a  groove  or  a  ridge, 
representing  the  absent  urethra.  The  glans  is  broadened  and  incurved,  mainly 
owing  to  imperfect  development  of  the  lower  portion  of  the  cavernous  bodies;  here 
the  fibrous  envelope  is  extremely  thick,  and  the  septum  between  the  two 
corpora  cavernosa  in  some  cases  participates  in  the  contraction. 


148 


GENITO-URINARY  SURGERY 


Glandular  and  penile  hypospadia  do  not  necessarily  interfere  with  either 
micturition  or  the  procreative  function.  By  lifting  the  glans  the  urine  may  be 
projected  in  an  almost  normal  direction,  and,  unless  incurvation  is  more  than 
usually  marked,  sexual  congress  is  possible,  but  fecundation  is  doubtful.  In 
the  scrotal  and  perineal  varieties  the  functions  of  both  micturition  and  copulation 
are  materially  interfered  with.  The  backward  curve  of  the  urethra  obstructs 
the  stream,  which  is  driven  out  with  some  force;  the  urine  is  usually  sprayed 


Fig.   81. — Penis     straightened     after 
transverse  cut  of  lower  surface. 


Fig.   82. — Transverse  wound  sutured 
longitudinally;  glandular  urethra  formed. 


in  all  directions,  requiring  the  patient  to  micturate  in  the  sitting  position  if  he 
wishes  to  avoid  soiling  his  clothing.  On  erection  the  incurvation  of  the  organ 
becomes  even  more  marked  than  before;  thus  copulation  is  impossible. 

Diagnosis.- — The  diagnosis  is  made  by  inspection. 

Under  some  circumstances  the  determination  of  sex  is  extremely  difficult 
in  cases  of  perineal  hypospadia.    Careful  examination  through  the  rectum  com- 


FlG.  83. — Freshened  areas  and  incisions  made 
in  forming  g.andular  uretlora. 


Glandular  urethra  closed  by 
sutures. 


bined  with  abdominal  palpation  will  in  some  cases  show  the  presence  of  either 
a  prostate  or  a  rudimentary  uterus. 

Prognosis. — The  prognosis  of  hypospadia,  from  both  a  functional  and  a 
cosmetic  standpoint,  is  fairly  good  when  the  testicles  have  descended  and  are 
normal  in  size. 

Treatment. — This  consists  in  the' correction  of  incurvation  of  the  penis 
where  this  exists,  and  the  prolongation  of  the  urethra  to  the  end  of  the  penis. 
This  can  be  accomplished  only  by  a  series  of  operations,  three  being  the  usual 


SURGERY  OF  THE  URETHRA 


149 


number;  more  are  frequently  required.  Flooding  with  urine  materially  inter- 
feres with  the  success  of  plastic  operations.  This  may  be  avoided  by  making 
a  perineal  fistula  at  the  time  the  incurvation  is  overcome. 

The  first  stage,  straightening  the  penis,  is  accomplished  by  a  transverse 
incision  across  its  under  surface,  dividing  the  fibrous  cord  which  so  frequently 
passes  from  the  hypospadic  opening  to  the  glans,  the  thickened,  contracted 
sheath  covering  in  the  surface  of  the  cavernous  bodies,  and  also,  if  necessary, 
a  portion  of  the  septum  between  these  two  bodies.  The  incision  may  be  carried 
as  deep  as  is  necessary  for  complete  straightening  of  the  curve;  this  often 
implies  section  into  the  substance  of  the  cavernous  bodies.  When  the  penis 
has  been  straightened  the  wound  is  united  by  means  of  sutures,  so  that  its 
long  axis  is  at  right  angles  to  the  line  of  the  original  incision  (Figs.  81  and  82). 


ml 


Fig.  84. — Beck's  operation  for  hypospadia. 


The  wound  is  dressed  with  a  narrow  strip  of  sterile  gauze  secured  in  place  by 
collodion.  A  few  turns  of  a  narrow  gauze  bandage  are  then  applied,  and  the 
penis  is  held  upward  against  the  body  between  two  layers  of  cotton,  a  crossed 
of  the  perineum  roller  bandage  or  a  jock-strap  securing  it  in  place.  Stitches  are 
removed  in  five  days.  The  penis  is  subsequently  held  by  dressings  in  the  same 
position  till  the  next  step  in  the  operation  is  undertaken. 

At  the.  time  the  penis  is  straightened  a  portion  of  the  second  stage  {i.e., 
the  formation  of  the  glandular  urethra)  is  accomplished.  Where  there  is  a  deep 
furrow  representing  the  roof  of  the  urethra,  freshening  of  its  lower  edges  and 
apposition  by  suture  may  be  sufficient.  Usually  a  deep  vertical  incision  or 
two  lateral  incisions,  one  on  the  upper  and  outer  wall  of  each  side  of  the  groove, 
will  be  required.     In  the  furrow  thus  deepened  is  laid  a  section  of  catheter 


150 


GENITO-URINARY  SURGERY 


corresponding  in  circumference  to  the  normal  calibre  of  the  urethra,  and  the 
freshened  edges  of  the  furrow  are  neatly  approximated  by  suture,  two  or 
three  silk  threads  being  used  (Fig.  83).  These  are  removed  in  ten  days.  The 
section  of  catheter  may  be  retained  by  tying  its  ends  together.  Before  proceed- 
ing to  the  formation  of  the  penile  urethra  it  is  well  to  wait  for  some  months, 
to  determine  whether  or  not  incurvation  of  the  penis  will  be  reproduced  by 
contraction. 

The  second  stage,  the  formation  of  the  new  urethra,  is  accomplished  by 
freeing  sufficient  of  the  urethra  already  present  to  permit  its  being  stretched  to 
the  required  length,  by  means  of  epithelial  grafts,  or  by  means  of  flaps  of  skin 
taken  from  the  penis  or  scrotum. 


Fig.  85. — Flap  operation  for  hypospadia. 

The  first  method.  Beck's  operation,^  should  be  used  only  when  the  hypospadia 
opening  is  close  to  the  glans,  and  there  is  little  or  no  incurvation  (see  Fig.  84). 

Bevan  -  describes  the  operation  illustrated  in  Fig.  86.  It  is  applicable  to 
cases  of  glandular  hypospadia,  and  to  those  of  the  penile  form  opening  within 
one  inch  of  the  glans.  It  does  not  shorten  the  under  surface  of  the  penis  as  does 
the  Beck  operation;  an  ideal  result  was  obtained  by  Bevan  in  his  single  case. 

The  free-graft  method  as  developed  by  Nove-Josserand  employs  skin  taken 
from  the  thigh  to  line  a  tunnel  made  subcutaneously  by  means  of  a  trocar.^ 

^Beck:  New  York  Medical  Journal,  January  29,  1898;  May  13,  1905;  and  August 
14,  1909. 

""  Journal  of  the  American  Medical  Association,  1917,  Ixviii,  p.  1032. 
'Nove-Josserand:  Arch.  gen.  de  chir.,  1909,  iii,  pp.  331-348. 


SURGERY  OF  THE  URETHRA 


151 


The  exact  plan  to  be  followed  in  forming  a  new  urethra  by  utilizing  flaps 
of  skin  from  the  penis  and  surrounding  structures  necessarily  varies  with  the 
requirements  of  the  individual  case.  Tension  is  fatal  to  vitality;  in  planning 
flaps  the  changes  likely  to  follow  erection  must  be  kept  in  mind. 

The  usual  plan  after  after  perineal  drainage  by  catheter  is  to  make  two  parallel 
incisions,  three-quarters  to  one  inch  apart,  on  the  under  surface  of  the  penis 
from  a  little  to  the  proximal  side  of  the  hypospadic  opening  to  the  base  of  the 
glans,  continuing  the  incision  about  both  openings,  and  dissect  up  flaps  toward 
the  median  line  sufficiently  long  to  permit  suture  of  their  edges  to  one  another 
(Fig.  85).  The  suture  is  continued  at  each  end  so  that  the  new  canal  unites 
with  the  natural  channel  and  the  recently  formed  balanic  portion.     The  raw 


Pullrng  flap, 
thru    glans 


UretJira 


FIG.  80. — JtJevan's  operation  for  hypospadia. 

area  formed  by  turning  over  the  flaps  may  be  covered  in  by  simply  drawing 
the  margins  of  the  skin  together  (if  sufficient  skin  be  present)  or  by  using  a 
flap  from  the  scrotum  or  the  prepuce  (buttonholing  it  so  that  it  can  be  slipped 
over  the  glans,  and  cutting  it  so  that  the  two  layers  can  be  separated). 

If  perineal  drainage  has  not  been  provided  for  by  urethrostomy  or  catheter, 
continuous  urethral  catheterization  is  indicated  for  seven  to  ten  days.  The  rubber 
causes  an  undue  inflammatory  reaction,  and  the  bulk  of  the  catheter  increases 
the  tension  on  the  sutures  and  the  danger  of  pressure  necrosis. 

The  postoperative  dressing  is  a  small  piece  of  sterile  gauze,  secured  by  a 
tight  circular  bandage  if  the  penis  be  large  enough  to  be  so  treated,  or  simply 
laid  on  loosely  if  bandaging  be  not  possible.     Erections  can  be  prevented  only 


152 


GEXITO-URIXARY  SURGERY 


by  almost  toxic  doses  of  the  bromides,  scopolamine,  and  morphine;  flaps  should 
therefore  be  of  such  proportions  as  to  allow  for  them.  Rest  to  the  part  (bed 
treatment  for  children,  and  good  bandage  or  athletic  supporter  for  adults)  is 
essential. 

The  perineal  fistula  should  not  be  closed  till  the  postoperative  inflammatory 
reaction  has  subsided,  and  the  new  urethra  takes  easily  a  sound  of  appropriate 
calibre  (28  F.  to  30  F.for  the  adult;  18  F.  to  22  F.  for  children).  The  closure 
is  effected  by  deeply  incising  the  mucocutaneous  junction  and  uniting  the  super- 
ficial tissue  and  skin  b}^  sutures. 

EPISPADIA 

In  this  deformity  a  portion  or  all  of  the  roof  of  the  uretura  is  aosent,  the 
canal  being  represented  by  a  furrow  traversing  the  mid-dorsal  aspect  of  the 
penis.  It  is  often  complicated  by  exstrophy  of  the  bladder,  and  is  sometimes 
associated  with  other  malformations,  such  as  urachal  fistula,  imperforate  anus, 
absence  of  the  prostate,  abnormalities  of  the  corpora  cavernosa,  etc.  This 
anomaly,  rare  in  all  its  forms,  may  appear  as  the  glandular  form  (i.e.,  the  urethra 


Fig.  87. — Usual  form  of  epispadia. 

is  complete  as  far  as  the  glans.  opening  just  behind  this  expansion  of  the  spongy 
body) ;  more  often  the  abnormal  opening  is  just  in  front  of  the  pubic  symphysis 
(Fig.  87),  or  rather  in  the  normal  position  of  this  junction,  since  in  many  of 
these  cases  the  pubic  rami  do  not  extend  to  the  middle  line. 

In  these  cases  the  penis  is  short,  broad,  curved  upward,  at  times  twisted; 
the  prepuce  is  redundant  below,  and  there  is  a  projecting  belly-fold  above, 
against  which  the  dorsum  of  the  glans  is  apposed.  On  drav^dng  this  down  the 
urethral  furrow  is  seen  lined  with  thin  mucous  membrane  and  passing  backward 


SURGERY  OF  THE  URETHRA 


153 


to  the  urethral  orifice  deeply  sunken  in  the  pubic  region.  This  orifice  is  usually 
large,  often  admitting  an  examining  finger  without  difficulty. 

Epispadia  is  often  attended  with  incontinence  of  urine,  though  when  the 
posterior  urethra  is  perfectly  formed  and  there  is  no  separation  of  the  pubic 
bones  micturition  may  be  accomplished  normally.  Except  in  cases  of  marked 
curvation  of  the  penis,  erection  and  intromission  are  possible. 

Treatment. — The  treatment  of  epispadia  is  either  palliative  {i.e.,  the  adapta- 
tion of  a  properly  fitting  portable  urinal  (see  "  Exstrophy  ") — or  radical — ' 
i.e'.,  by  operative  measures.  Here,  as  in  hypospadia,  plastic  repair  is  difficult, 
and  is  accomplished  as  the  result  of  a  series  of  operations,  planned  with  due 
respect  to  the  character  of  the  tissues  available  in  the  individual  case.  Flaps 
subject  to  tension  or  of  poor  vitality  will  not  hold;  it  is  therefore  quite  useless 
to  use  such  tissue. 

The  following  is  a  description  of  Thiersch's  method: 

There  are  five  distinct  periods  of  the  operation. 

The  first  period  is  devoted  to  the  formation  of  a  perineal  fistula.  This  is 
readily  done  by  inserting  into  the  urethra  a  curved  forceps.  The  end  of  the 
latter  is  pressed  downward  and  forward  into  the  perineum  and  cut  open,  care 
being  taken  not  to  injure  the  rectum.  This  can  be  guarded  against  by  passing 
a  finger  of  the  left  hand  into  the  anus  while  the  perineal  cut  is  being  made. 


Fig. 


-Formation  of  glandular  urethra.     A,  freshened  areas  on  each  side  of  furrow.     B,  deep 
incisions  on  dorsum  of  glans. 


The  bladder  having  been  thus  opened,  a  Guyon  self-retaining  rubber  catheter 
is  introduced.  If  there  has  been  excoriation  of  skin  from  leaking  and  decom- 
position of  urine,  it  is  well  to  postpone  the  further  steps  of  the  operation  until 
thorough  cleansing  of  the  parts  and  the  application  of  astringent  and  mildly 
antiseptic  dusting  powders  have  subdued  all  irritation.  This  perineal  fistula, 
by  diverting  the  urine  from  the  seat  of  subsequent  operations,  enables  the 
surgeon  to  avoid  the  dangers  and  delays  incident  to  suppuration,  which  almost 
inevitably  occurs  when  the  urine  is  allowed  to  escape  in  its  natural  course. 

The  second  step  of  the  operation  consists  in  the  formation  of  a  glandular 
urethra.  To  the  right  and  left  of  the  glandular  furrow,  parallel  with  the  latter, 
running  the  whole  length  of  the  glans,  and  in  depth  equalling  three-fourths  of 
its  thickness,  there  are  made  incisions  converging  to  such  an  extent  that  were 
they  continued  to  the  lower  surface  of  the  glans  they  would  meet  (Fig.  88). 
By  these  cuts  there  are  formed  two  lateral  flaps  and  a  middle  wedge-shaped 
piece  of  glandular  tissue,  the  broad  base  of  the  latter  looking  upward  and  being 
covered  with  epidermis.  Along  the  outer  border  of  each  incision  there  is  re- 
moved a  strip  of  the  glandular  covering,  so  that  when  these  lateral  flaps  are 


154 


GEXITO-URIXARY  SURGERY 


brought  together  fresh  surfaces  of  sufficient  breadth  to  assure  firm  union  will 
be  apposed.  These  lateral  flaps  are  approximated  over  the  middle  wedge  and 
united  by  two  or  three  harelip  pin  sutures.  The  canal  thus  formed  is  more 
deeply  placed  at  its  orifice  than  in  the  region  of  the  corona,  though  this  is  of 
minor  consequence.  Obhteration  of  this  canal  is  impossible,  since  the  epithelial 
covering  of  the  middle  wedge  prevents  it. 

The  next  step  of  the  operation  consists  in  transforming  the  penile  furrow 
into  a  canal.  Close  to  the  right  border  of  the  furrow  there  is  made  a  longitudinal 
incision  di\iding  the  skin  and  the  subcutaneous  tissues  the  entire  length  of  the 
furrow  (Fig.  89).  From  either  end  of  this  incision  a  transverse  cut  is  made 
running  outward,  thus  outlining  a  long  quadrilateral  flap.    This  is  dissected  up 


Fig.  89. — Outlining  of  flaps  to  form  penile 
uretlira. — A,  flap  dissected  outward;  B,  flap 
dissected  inward. 


Fig.  90. — A.  Flaps  folded  over  and  held 
in  position  by  sutures. — Long  flap  drawn 
to  the  left  side  of  the  penis;  stitches  holding 
the  short  inner  flap  in  position. 


Cross-section  of  same,  showing  the  direction 
in  which  the  flaps  are  dissected. 


Cross-section  of  same 


with  as  much  subcutaneous  tissue  as  possible,  especially  near  the  base  of  the 
flap.  A  similar  long  incision  is  made  to  the  left  of  the  furrow,  about  two-fifths 
of  an  inch  from  its  edge.  From  each  end  of  this  incision  a  transverse  cut  is 
carried  inward  as  far  as  the  edge  of  the  furrow.  This  flap  is  also  dissected  up 
with  as  much  subcutaneous  tissue  as  possible.  It  is  then  turned  over  exactly 
as  one  turns  the  leaf  of  a  book  from  right  to  left,  so  that  its  epithelial  surface 
forms  the  roof  of  the  furrow,  while  its  wound  surface  is  turned  outward.  If  the 
flap  is  sufficiently  wide  to  cover  in  the  furrow  entirely  without  undue  tension, 
three  or  four  mattress  sutures  are  passed  through  its  free  border  and  the  base 
of  the    right  flap  and  tied  on  the  skin  surface.     The  first  or  right  flap  is  now 


SURGERY  OF  THE  URETHRA 


155 


drawn  directly  over  this  flap  which  has  been  turned  over,  thus  approximating 
the  two  fresh  surfaces  of  the  flaps,  and  sutured  in  this  position  (Fig.  90). 

The  canal  thus  formed  is  lined  with  skin  and  is  of  the  right  calibre.    There 
is  no  danger  of  the  flaps  sloughing  provided  they  have  been  left  sufficiently 


Fig.  91. — 1.  Transverse  defect  between 
penile  and  glandular  urethras;  2,  3,  oblique 
incision   through   foreskin.      (Thiersch.) 


Fig.  92. — Foreskin  brought  up  behind  the 
glans,  and  line  of  sutures  uniting  freshened 
edges  of  transverse  defect  to  foreskin. 


thick  at  their  base  and  have  been  dissected  so  freely  that  there  is  no  tension. 
Should  there  be  dangerous  tension,  two  long  incisions  are  made  to  the  right 
and  left  of  the  lower  mid-line  of  the  penis.  These  are  carried  down  to  the 
fibrous  sheath,  and  are  allowed  to  heal  by  granulation. 


Fig.  93. — Closing  posterior  defect. — Forma- 
tion of  flaps  X  and  Y;  suture  of  first  flap. 


Fig.  94. — Suture  of  second  flap. 


The  next  step  of  the  operation  consists  in  the  union  of  the  glandular  and 
penile  urethras.  This  is  made  at  the  expense  of  the  foreskin.  The  transverse 
defect  existing  between  the  penile  and  the  glandular  urethra  is  first  widely 
freshened.     The  foreskin  is  stretched  out  and  an  oblique  incision  is  made 


156 


GENITO-URINARY  SURGERY 


entirely  through  it,  forming  an  opening  sufficiently  large  to  allow  the  glans  to 
slip  through  (Fig.  91).  The  lower  half  of  the  foreskin  is  thus  by  its  raw  surface 
closely  applied  to  the  corona.  The  foreskin  having  been  brought  up  in  place, 
one  of  its  layers  is  carefully  sutured  to  the  upper  border  (formed  by  the  new 
urethral  roof)  of  the  defect,  and  the  other  border  is  secured  to  the  freshened 
corona  glandis  (Fig.  92).  It  is  necessary  carefully  to  separate  the  two  layers 
of  the  foreskin,  otherwise  they  will  unite  to  each  other  instead  of  to  the  freshened 
surfaces. 

The  final  step  of  the  operation  consists  in  closing  the  posterior  defect,  and 


.'.    v 


Fig.  95. — Cured  epispadia.     (Thiersch.) 

is  accomplished  by  means  of  two  flaps  cut  from  the  surrounding  belly  walls. 
The  first  flap  is  formed  from  the  left  side.  It  is  in  the  shape  of  an  equilateral 
triangle,  with  its  base  corresponding  to  the  left  half  of  the  skin  surface  lying 
immediately  above  and  to  the  left  of  the  roof  of  the  urethral  orifice  (Fig.  93). 
The  corner  of  this  flap  is  folded  downward  and  inward  so  that  its  skin  surface 
covers  in  the  defect.     Its  lower  free  border  is  sutured  to  the  freshened  upper 


SURGERY  OF  THE  URETHRA  157 

border  of  the  new  roof  formed  by  transplantation  of  the  penile  skin.  The  second 
flap  approximates  the  form  of  a  quadrilateral  with  its  attached  base  in  the  region 
of  the  right  inguinal  canal.  This  flap  is  drawn  downward  and  inward  so  that 
its  freshened  surface  covers  in  the  fresh  surface  of  the  first  flap.  It  is  secured 
in  this  position  by  sutures,  including  both  the  lower  flap  and  the  borders  of 
the  skin  incision  required  for  the  preparation  of  the  triangular  flap  (Fig.  94). 
The  raw  surface  left  after  this  transplantation  is  allowed  to  heal  by  granulation. 

Healing  of  the  perineal  fistula  completes  the  operation.  This  is  readily 
accomplished  by  removing  the  tube. 

In  Thiersch's  own  case  (Fig.  95)  it  required  about  one  and  a  half  years. 
He  holds  that  ordinarily  it  should  be  accompHshed  in  three  or  four  months. 
He  advises  that  the  various  steps  of  the  operation  be  performed  in  the  order 
given,  allowing  fourteen  days  for  the  formation  of  the  perineal  fistula,  fourteen 
days  for  forming  the  glandular  urethra,  twenty-one  days  for  closure  of  the  perineal 
furrow,  fourteen  days  for  transplantation  of  the  foreskin,  and,  finally,  for  the 
closure  of  the  urethra  and  the  subsequent  operations  which  may  be  necessary, 
forty-two  days. 

INJURIES  OF  THE  URETHRA 

The  urethra  may  be  wounded  or  -subcutaneously  ruptured. 

Wounds  of  the  urethra  are  surgical  or  accidental.  Accidental  wounds  are 
rare. 

Incised  wounds  of  the  urethra,  if  longitudinal,  heal  readily  and  often 
without  subsequent  stricture,  even  though  no  sutures  are  applied.  When  such 
injuries  are  inflicted  from  without,  either  intentionally  by  the  surgeon,  as  in  the 
case  of  external  urethrotomy,  or  as  a  result  of  accident,  provided  the  urethra  is 
healthy  and  the  urine  sterile,  the  wound  may  be  sutured,  the  urethra  being 
first  closed  by  fine  buried  catgut  sutures,  not  including  the  epithelial  coat,  and 
the  skin,  subcutaneous  tissues,  and  spongy  body  being  approximated  by  a  second 
row  of  interrupted  fine  silkworm-gut  sutures.  When  the  urethra  is  suppurating 
the  wound  should  be  allowed  to  heal  by  granulation.  When  the  urethral  wound 
is  not  extensive  it  is  not  necessary  to  employ  stitches. 

When  the  urethra  is  incised  transversely  there  is  free  bleeding,  and,  if  the 
canal  is  cut  completely  across,  the  proximal  end  retracts.  Healing  by  granu- 
lation always  implies  a  degree  of  coarctation  depending  on  the  extent  of  the 
wound.  When  the  urethra  is  completely  divided,  the  proximal  end  may  be 
found  by  retrograde  catheterization  through  a  suprapubic  opening  in  case  it  has 
retracted  so  that  it  is  not  easily  secured  in  the  wound.  The  divided  urethral 
ends  must  then  be  held  in  neat  apposition  by  interrupted  catgut  sutures  placed 
one-eighth  of  an  inch  apart  and  not  penetrating  the  epithelial  layer.  When 
the  continuity  of  the  roof  of  the  urethra  is  thus  restored  by  three  or  four  sutures, 
a  soft  catheter  is  passed  into  the  bladder,  the  urethral  suture  is  completed,  the 
external  wound  is  closed,  and  the  catheter  is  tied  in  place;  as  in  all  cases  of 
continuous  catheterization,  the  bladder  and  urethra  receive  frequent  antiseptic 
irrigations. 

Always  after  the  healing  of  transverse  wounds  of  the  urethra  involvin*^  more 


158  GENITO-URINARY  SURGERY 

than  one-third  of  the  circumference  of  the  canal  a  sound  should  be  passed  at 
first  once  a  week,  then  at  longer  intervals,  till  there  is  no  tendency  to  stricture 
formation. 

Lacerated  and  contused  wounds  of  the  urethra  are  cleansed,  opened  so 
that  drainage  both  of  urine  and  of  wound  discharges  is  freely  provided  for, 
and  allowed  to  heal  by  granulation,  continuous  catheterization  being  main- 
tained till  the  urethral  defect  is  entirely  closed  in.  Patients  after  these  injuries 
must  be  instructed  as  to  the  probable  necessity  for  the  occasional  passage  of  a 
sound  during  the  remainder  of  their  lives. 

Whenever,  because  of  the  limited  extent  of  a  lacerated  and  contused  wound,, 
there  is  sufficient  tissue  left,  after  trimming  away  that  which  is  devitalized, 
to  allow  of  urethral  suture,  this  procedure  should  always  be  adopted,  since  thus 
subsequent  stricture  may  be  lessened  or  entirely  prevented. 

Punctured  vs^ounds,  when  from  without,  are  not  attended  by  extravasation, 
and  require  simply  the  application  of  wet  antiseptic  and  evaporating  lotions, 
as,  for  instance,  lead  water  and  alcohol,  to  limit  inflammatory  reaction.  When 
the  urine  is  sterile  no  intra-urethral  treatment  is  required.  When  it  is  infected, 
and  particularly  when  the  urethra  is  inflamed,  as  in  acute  or  chronic  gonorrhoea, 
irrigation  with  protargol  solution  1  to  2000,  or  bichloride  1  to  20,000  is  indicated. 

When  the  punctured  wound  is  from  within,  as  in  the  formation  of  a  false 
passage,  free  bleeding  and  the  detection  of  the  point  of  the  instrument  outside 
the  urethra  by  external  or  rectal  palpation  show  the  nature  of  the  injury. 
Usually  such  wounds  heal  spontaneously  without  becoming  infected,  even  though 
infection  of  the  urethra  has  existed  previously.  Exceptionally  they  suppurate, 
forming  abscesses. 

The  treatment  of  such  wounds  consists  in  refraining  from  further  instru- 
mentation, making  the  urine  slightly  antiseptic  by  appropriate  medication,  and 
using  mild  antiseptic  irrigation,  1  to  2000  protargol  or  1  to  6000  permanganate, 
under  low  pressure  (elevation  of  reservoir,  three  feet).  In  case  of  local  and 
general  symptoms  pointing  to  suppuration,  drainage  must  be  provided  for  by 
external  incision. 

Rupture  of  the  Urethra. — Subcutaneous  rupture  of  the  urethra  when  seen 
in  the  penile  portion  of  the  canal  is  usually  the  result  of  the  breaking  of  chordee, 
fracture  of  the  penis,  or  twisting,  wrenching  or  pinching  force  applied  to  the 
erect  organ.  The  penis  is  so  movable  that  it  usually  escapes  the  crushing  effect 
of  force  applied  in  the  form  of  blows  and  kicks.  Subcutaneous  rupture  is 
commonly  observed  in  the  perineal  urethra.  Kaufmann,  as  the  result  of  a  sta- 
tistical study  of  over  two  hundred  cases,  gives  as  the  form  of  injury,  falling 
astride  eighty  per  cent.,  perineal  blows  twelve  per  cent.,  being  run  over  by 
vehicles  four  per  cent.,  being  unseated  upon  the  pommel  of  the  saddle  four 
per  cent. 

The  mechanism  of  the  perineal  rupture  depends  upon  the  shape  of  the  vul- 
nerating  body  and  the  direction  in  which  the  force  is  applied.  Where  there 
is  a  fall  astride  upon  a  narrow  body,  as,  for  instance,  the  edge  of  a  half-inch 
plank,  this  is  forced  upward  between  the  ischiopubic  rami,  usually  a  little  to 
one  side,  tears  the  triangular  ligament,  and  crushes  the  urethra  against  the  ischio- 


SURGERY  OF  THE  URETHRA  159 

pubic  ramus.  When  the  vulnerating  body  is  larger,  as,  for  instance,  the  square 
toe  of  a  boot,  the  urethra  is  driven  directly  upward  against  the  lower  or  anterior 
surface  of  the  pubis,  the  lower  portion  of  the  urethra  rupturing  first.  Together 
with  the  urethral  rupture  there  are  always  contusion  of  the  bulb,  of  the  perineal 
tissues,  and  often  of  the  attachment  of  the  cavernous  bodies. 

The  seat  of  contusion  and  laceration  of  the  urethra  is  usually  in  the 
bulbous  part  of  the  urethra,  except  when  there  is  fracture  of  the  pelvis  or 
disjunction,  temporary  or  permanent,  of  the  pubic  symphysis,  in  which  cases 
the  membranous  urethra  is  involved. 

The  rupture  may  be  partial  or  complete.  In  the  mildest  cases  the  spongy- 
tissue  is  the  only  part  involved.  There  results  in  consequence  a  temporary- 
narrowing  or  blocking  of  the  urethra,  due  to  circumscribed  blood  effusion  into 
the  loose  erectile  tissue  of  the  spongy  body.  In  more  severe  cases  both  the 
spongy  body  and  the  mucous  and  sub-mucous  layers  of  the  urethra  are  crushed 
and  torn.  In  the  most  severe  cases  not  only  is  the  urethra  with  the  sur- 
rounding spongy  body  injured,  but  likewise  the  fibrous  investment  of  the  latter,, 
thus  making  a  direct  communication  from  the  floor  of  the  urethra  to  the  loose 
cellular  tissue  of  the  scrotum  and  the  perineum. 

The  rupture  may  involve  the  entire  lumen  of  the  tube,  or,  as  is  more  fre- 
quently the  case,  may  include  only  its  lower  and  lateral  wall.  In  cases  of  com- 
plete transverse  laceration  there  is  always  marked  retraction,  leaving  a  space 
from  one-half  to  three-fourths  of  an  inch,  at  first  filled  with  blood-clot,  later 
converted  into  an  abscess. 

Symptoms. — The  symptoms  of  laceration  of  the  urethra  are  urethral  hemor- 
rhage, the  immediate  formation  of  a  circumscribed  tumor  at  the  seat  of  injury,, 
retention  of  urine,  and  pain. 

The  amount  of  bleeding  from  the  urethra  cannot  be  regarded  as  an  index 
of  the  severity  of  the  lesion.  Blood  escaping  from  the  meatus  after  trauma 
always  indicates  laceration  of  the  mucous  membrane  at  least,  and  even  though 
but  a  small  quantity  is  lost,  as  in  the  breaking  of  a  chordee  or  from  a  false 
movement  in  coitus,  there  is  liable  to  result  periurethral  inflammation,  with  the 
ultimate  formation  of  an  unyielding  stricture. 

The  immediate  perineal  swelling  is  due  to  extravasated  blood.  Sldn  dis- 
coloration appears  after  one  or  two  days.  When  extravasation  of  infected 
urine  takes  place  there  are  the  symptoms  of  deep  cellulitis,  involving  the 
scrotum  and  penis  and  extending  upward  over  the  abdomen.  When  there  is 
total  rupture  retention  is  due  to  separation  of  the  urethral  ends  and  the  inter- 
position between  them  of  masses  of  coagulated  blood.  In  cases  of  partial 
rupture,  obstruction  of  the  tube  from  blood-clot  and  urethral  spasm  incident  to 
the  injury  may  be  operative  in  causing  retention.  Retention  developing  some 
time  after  the  accident  is  due  to  obstruction  caused  by  inflammatory  swelling. 

In  rupture  of  the  posterior  urethra  there  may  be  neither  bleeding  from  the 
meatus  nor  any  sign  of  perineal  tumor.  When  urinary  extravasation  takes 
place  it  occurs  in  the  deep  tissues,  and  produces  no  symptoms  until  cellulitis 
has  been  set  up.  In  cases  of  this  character  there  is  retention  of  urine;  obstruc- 
tion is  not  felt  on  introduction  of  the  catheter  until  it  has  penetrated  to  the 
depth  of  six  inches  and  is  passing  through  the  subpubic  urethra.    Then  either 


160  GENITO-URINARY  SURGERY 

its  further  progress  is  arrested,  or  if  it  passes  into  the  bladder  and  remains  un- 
obstructed by  blood-clot  there  flows  urine  mixed  with  blood.  In  ruptures  of  the 
anterior  urethra,  when  the  bladder  is  once  reached  by  instrumentation,  the 
urine  is  clear. 

The  consequences  of  rupture  of  the  urethra  are  urinary  extravasation, 
septic  infection,  and  later  traumatic  stricture.  At  each  act  of  micturition  urine 
is  liable  to  be  forced  into  the  periurethral  cellular  tissue,  extending  at  once 
into  the  scrotum  or  the  perineum  if  the  fibrous  envelope  of  the  bulb  has  been 
torn.  This  urine,  even  if  originally  sterile,  shortly  becomes  infected,  sets  up 
cellulitis,  and  occasions  sloughing  and  gangrene,  which,  unless  the  case  is 
promptly  attended  to,  result  in  death.  In  consequence  of  the  nature  of  the 
injury  (i.e.,  a  crush)  there  is,  when  the  canal  is  not  torn  completely  across, 
more  or  less  sloughing,  with  subsequent  cicatricial  contraction,  and  often  a  most 
obstinate  fistula.  When  the  ruptured  ends  of  the  urethra  have  not  been  apposed, 
there  is  formed  between  them  a  granulating  sinus,  whose  walls  exhibit  all  the 
vices  of  cicatricial  tissue.  Because  of  its  common  association  with  fractured 
pelvis,  the  prognosis  of  rupture  of  the  membranous  urethra  is  guarded. 

Diagnosis. — The  history  of  the  injury,  the  perineal  tumor  of  sudden  forma- 
tion, blood  from  the  meatus,  either  flowing  spontaneously  or  induced  to  appear 
by  pressure  on  the  perineal  tumor,  are  sufficient  to  justify  an  absolute  diagnosis 
of  rupture  of  the  anterior  urethra.  Bleeding  is  in  itself  diagijostic  when  it 
follows  traumatism,  and  in  the  absence  of  perineal  tumor  and  marked  dysuria 
denotes  simply  a  slight  tear  of  the  mucous  membrane  without  involvement 
of  the  periurethral  tissues.  A  rapidly  formed  perineal  tumor  associated  with 
dysuria  or  retention  usually  signifies  an  extensive  laceration.  The  seat  of 
rupture  is  indicated  by  local  tenderness  and  often  by  the  signs  of  external 
violence.  The  history  of  the  injury  is  also  of  importance  in  determining  this 
point.  Thus,  when  there  has  been  a  fall  astride  of  a  comparatively  wide  sur- 
face, such  as  a  joist  or  the  pommel  of  a  saddle,  the  bulbous  urethra  is  almost 
certainly  involved.  If  the  injury  has  resulted  from  a  fall  on  the  edge  of  a 
board,  for  instance,  it  is  probable  that  the  membranous  urethra  is  ruptured. 
In  cases  of  pelvic  fracture  or  disjunction  the  diagnosis  is  sometimes  extremely 
difficult.  There  is  little  deformity,  and  crepitus  may  not  be  elicited.  There 
may  be  bleeding  from  the  meatus,  but  usually  the  spasm  of  the  compressor 
urethras  muscle  causes  the  blood  to  flow  back  into  the  bladder.  The  history 
of  the  injury — commonly,  in  case  of  fracture,  a  crushing  force  applied  to  the 
two  sides  of  the  pelvis — the  detection  of  crepitus  by  rectal  examination,  the 
almost  invariable  development  of  urinary  retention,  and  the  difficulty  in  cathe- 
terization or  the  drawing  off  from  the  bladder  of  blood  with  the  urine,  would 
point  to  rupture  of  the  membranous  urethra. 

Treatment. — In  the  least  serious  cases  {i.e.,  those  characterized  by  moderate 
hemorrhage  from  the  meatus,  either  with  or  without  circumscribed  nonpro- 
gressive tumor-formation  in  the  perineal  region,  and  not  complicated  by  reten- 
tion) the  use  of  pressure,  together  with  the  application  of  hot  compresses,  the 
administration  of  urinary  antiseptics  by  the  mouth,  rest  in  bed,  free  purgation, 
and  mild  antiseptic  irrigation  of  the  urethra,  may  bring  about  cure.  The 
catheter  should  not  be  used  unless  dysuria  or  retention  makes  it  necessary. 


SURGERY  OF  THE  URETHRA  161 

Under  these  circumstances  a  large,  soft,  elbowed  gum  instrument  should  be  em- 
ployed; and  it  should  be  introduced  and  withdrawij  with  a  solution  of  protargol 
(1  to  2000;  flowing  through  it  from  a  fountain  syringe  elevated  not  more  than 
two  feet  above  the  bladder  level. 

Perineal  section  is  indicated  in  the  presence  of  urinary  retention  when  a 
catheter  cannot  be  passed  into  the  bladder,  also  by  persistent  hemorrhage, 
evidenced  by  progressive  tumor  formation  or  hsematuria,  in  spite  of  continuous 
catheterization,  and  by  cellulitis. 

The  operation  is  conducted  in  accordance  with  the  principles  laid  down  on 
page  285.  Acatheter  or  staff  is  passed  to  the  seat  of  rupture,  and  the  perineum 
is  opened  upon  this  in  the  middle  line.  This  can  be  done  under  local  anaesthesia. 
The  incision  should  be  free.  On  opening  the  deep  layer  of  the  superficial  fascia 
there  is  found  a  cavity  filled  with  clots,  with,  in  recent  cases,  bleeding  still 
persisting. 

Guided  by  the  catheter,  the  urethra  is  readily  identified,  threads  are 
passed  through  its  two  sides  to  act  as  retractors,  and,  in  case  the  canal  is 
not  completely  torn  across,  the  catheter  is  readily  passed  into  the  bladder. 
Bleeding  points  are  then  secured  by  ligature,  and  the  urethral  rent  is  closed,  if 
possible,  by  interrupted  chromicized  gut  sutures,  including  in  their  grip  as 
much  periurethral  tissue  as  possible.  The  cavity  resulting  from  the  bleeding 
is  closed  by  buried  catgut  sutures  and  the  skin  is  secured  by  silkworm-gut. 
The  catheter  is  left  in  place  from  four  to  six  days. 

If  the  urethra  is  completely  torn  across,  and  the  proximal  urethral  end  is 
not  discovered  after  a  brief  but  careful  search,  Guyon  advises  the  passage  of 
a  sound  from  the  meatus  till  its  extremity  is  arrested  by  the  posterior  wall 
of  the  cavity  made  by  the  blood  extravasation.  The  left  index  finger  is  then 
passed,  palmar  side  up,  to  the  point  pressed  upon  by  the  tip  of  the  sound. 
The  latter  is  slightly  withdrawn,  and  in  many  cases  just  above  the  position 
occupied  by  the  end  of  the  finger  will  be  found  the  proximal  end.  Through  it, 
guided  by  the  finger,  may  be  passed  an  instrument  from  the  perineum  into  the 
bladder.  Sudden  bimanual  pressure  on  the  bladder  by  the  fingers  of  one  hand 
in  the  rectum  and  of  the  other  over  the  hypogastric  region  may  cause  a  few 
drops  of  urine  to  exude,  and  thus  show  the  position  of  the  torn  mucous  channel, 
which  in  recent  cases  is  found  to  be  a  movable  bleeding  cord.  When  local 
anaesthesia  has  been  employed,  the  patient  may  aid  the  surgeon  by  efforts  at 
micturition. 

When  the  case  has  advanced  to  abscess-formation  and  extensive  sloughing, 
or  when  the  rupture  has  occurred  as  a  complication  of  pelvic  fracture,  it  may 
be  impossible  to  find  the  proximal  end  of  the  urethra  except  by  means  of 
retrograde  catheterization  practised  through  a  suprapubic  opening  made  in 
the  bladder. 

The  proximal  end  of  the  urethra  having  been  found,  a  soft  rubber  catheter 
is  passed  from  the  meatus  into  the  bladder,  and  the  ragged  or  irregular  wound 
edges  are  trimmed  off,  and  approximated  over  the  catheter  by  means  of  chromi- 
cized cateut  sutures,  taking  in  the  periurethral  tissues.  This  suture  is  made 
easy  by  thrusting  the  proximal  end  of  the  urethra  downward  and  forward  well 
into  the  wound  by  means  of  a  fineer  inserted  into  the  rectum.  Often  union 
does  not  take  place;  but,  even  though  it  fails,  less  cicatricial  tissue  is  formed 
11 


162  GENITO-URINARY  SURGERY 

than  when  there  has  been  no  attempt  at  suture.  When  there  is  no  local  infec- 
tion the  whole  wound  is  closed  by  buried  catgut  sutures,  an  antiseptic  dressing 
being  held  in  place  either  by  a  T-bandage  or  by  a  crossed  of  the  perineum. 
Continuous  catheterization  is  employed  for  six  days  (see  p.  73).  After  the 
catheter  is  withdrawn  a  full-sized  sound  is  passed  every  three,  four,  or  five 
days  for  some  weeks,  and  is  afterwards  continued  at  longer  intervals  for  months 
or  years. 

Even  when  operation  is  delayed,  and  infiltration  and  septic  inflammation 
have  already  occurred,  approximation  of  the  torn  urethral  ends  should  be 
attempted  by  suture. 

There  should,  however,  be  no  effort  to  close  the  infected  cavity,  this  being 
cleansed  and  packed  with  sterile  or  iodoform  gauze  and  allowed  to  granulate 
from  the  bottom. 

FOREIGN  BODIES  IN  THE  URETHRA 

Foreign  bodies  in  the  urethra  are  either  introduced  from  without  or  pass 
forward  from  the  bladder,  in  the  latter  case  appearing  as  urinary  calculi  or 
fragments  of  neoplasm.  The  bodies  introduced  from  without  are  usually  seg- 
ments of  catheter,  the  instruments  employed  being  old"  and  breaking  during 
introduction  or  withdrawal.  In  the  case  of  social  perverts  almost  any  object, 
if  sufficiently  small,  may  be  passed  into  the  urethra.  Exceptionally,  animal 
parasites  may  be  found. 

The  behavior  of  a  foreign  body  lying  completely  within  the  urethra  depends 
upon  its  shape  and  size.  When  it  is  smooth  and  rounded,  as,  for  instance,  in  the 
case  of  a  broken  fragment  of  catheter,  a  small  wax  candle,  or  a  piece  of  lead 
pencil,  it  nearly  always  exhibits  a  tendency  to  pass  back  into  the  bladder. 
This  occurs  in  about  thirty  per  cent,  of  all  cases,  and  is  due  to  the  constant 
handling  of  the  parts  by  the  patient,  and  to  the  frequent  erections  reflexly 
excited  by  the  presence  of  the  foreign  body. 

A  smooth,  not  too  large  foreign  body  may  pass  back  into  the  bladder  in  less 
than  a  day. 

Should  the  foreign  body  remain  in  the  urethra,  the  navicular  fossa,  the  bulb, 
and  the  prostatic  urethra  are  its  seats  of  preference,  these  portions  of  the  canal 
representing  the  regions  of  greatest  dilatation. 

Symptoms. — Localized  pain,  interference  with  micturition,  and  inflammatory 
phenomena  are  the  characteristic  symptoms  of  foreign  body  in  the  urethra. 

The  pain  is  usually  severe,  especially  when  the  foreign  body  is  irregular 
in  shape.  When  the  catheter  is  broken  off  in  a  urethra  which  has  long  been 
tolerant  of  instrumentation,  there  may  be  no  suffering,  especially  if  the  broken 
end  is  lodged  in  the  membranous  or  prostatic  portion.  Foreign  bodies  located 
in  the  posterior  urethra,  particularly  if  irregular  in  shape,  with  sharp  corners  or 
angles,  cause  pain  characteristic  of  posterior  urethritis;  i.e.,  there  is  a  deep 
ache  felt  in  the  perineum,  with  itching,  burning,  or  a  sense  of  weight  and 
dragging  in  the  rectum,  and  shooting  or  persistent  pain  in  the  hypogastric 
region,  about  the  sacro-iliac  articulation,  and  radiating  down  the  inner  surfaces 
of  the  thighs. 


SURGERY  OF  THE  URETHRA  163 

Interference  with  micturition  depends  mainly  upon  the  size  and  position 
of  the  fcreign  body  and  upon  the  amount  of  inflammatory  reaction  its  presence 
sets  up.  Immediate  retention  is  rare.  There  are  always  increased  fre- 
quency of  urination  and  lessening  in  the  force  and  volume  of  the  stream. 
Unless  the  body  is  removed  or  passes  back  into  the  bladder,  micturition 
becomes  progressively  more  difficult  and  painful  because  of  swelling  due  to 
inflammation. 

Inflammatory  phenomena  are  quickly  developed.  When  the  body  is  lodged 
in  the  anterior  urethra,  there  is  shortly  a  blood-stained  muco-purulent  discharge, 
with  redness,  heat,  and  swelling  of  the  penis.  This  is  commonly  accompanied 
by  fever. 

When  the  body  is  lodged  in  the  posterior  urethra,  increased  tenderness  on 
perineal  and  rectal  palpation,  the  appearance  of  constitutional  symptoms, 
and  often  the  development  of  cystitis  or  epididymitis,  show  extension  of 
inflammation. 

Diagnosis. — The  history  of  the  case  is  usually  sufficient  to  establish  the 
diagnosis.  In  the  case  of  a  sexual  pervert,  a  reliable  history  may  be  entirely 
wanting.     The  symptoms  in  themselves  are  merely  suggestive,  since  pain,  fre- 


FlG.  96. — Urethral  forceps. 

quent  and  obstructed  urination,  and  urethritis  may  develop  from  a  variety 
of  causes. 

Direct  examination,  even  in  the  absence  of  history,  nearly  always  makes  the 
nature  of  the  case  plain.  Palpation  usually  shows  the  size,  shape,  and  seat  of 
the  body  if  it  is  located  in  the  anterior  urethra.  Rectal  palpation  is  employed 
when  the  foreign  body  is  farther  back. 

Providing  the  urethra  is  not  strictured,  the  urethroscope  can  always  be 
depended  upon  to  bring  the  foreign  body  into  view.  This  instrument  also 
enables  the  surgeon  to  determine  the  amount  of  impaction,  and  to  choose  and 
apply  his  extracting  instruments  so  that  they  shall  act  to  the  greatest  mechanical 
advantage. 

In  introducing  the  urethroscopic  tubes,  care  must  be  used  not  to  push  the 
foreign  body  in  still  farther. 

In  the  absence  of  an  urethroscope  a  small  sound  may  be  used  for  purpose 
of  diagnosis  and  localization. 

A  foreign  body  introduced  into  the  urethra,  if  neither  expelled  nor  extracted, 
may  pass  back  into   the  bladder  or  may  remain  in   the  urethra,   becoming 


164  GENITO-URINARY  SURGERY 

incnisted  with  urinary  salts  and  causing  ulceration  which  is  prone  to  extend 
through  the  urethral  wall,  forming  a  suppurating  cavity  which  opening  ex- 
ternally may  result  in  an  obstinate  urethral  fistula.  It  is  in  the  prostatic  urethra 
that  foreign  bodies  are  most  apt  to  remain  indefinitely,  causing  slow  ulceration, 
and  becoming  so  embedded  in  inflammatory  material  that  their  detection  may 
be  extremely  difficult. 

A  foreign  body  once  lodged  within  the  urethra  if.  not  expelled  with  the 
first  subsequent  act  of  micturition  is  not  likely  to  be  expelled  afterwards. 
Inflammatory  swelling  fixes  it  more  firmly,  and  from  reflex  irritation  causing 
frequent  urination  the  stream  loses  in  volume  and  force. 

Treatment. — The  simplest  method  of  ridding  the  urethra  of  the  foreign  body, 
and  one  which  may  succeed  providing  the  case  be  seen  immediately  after  its 
introduction,  is  to  direct  the  patient  to  urinate  forcibly.  When  the  stream  is 
fairly  started  the  lips  of  the  meatus  are  pressed  together  for  four  or  five  seconds 
and  are  then  suddenly  released.  This  failing,  recourse  should  be  had  at 
once  to  forceps,  manipulated  through  an  urethroscope  (Fig.  96).  In  grasp- 
ing the  body  with  forceps  it  should  be  pressed  forward  from  behind  by 
perineal  or  rectal  pressure,  thus  avoiding  the  danger  of  pushing  it  back  into 
the  bladder. 

If  the  forceps  fail  to  grasp  the  body,  or  if  because  of  its  angular  shape  with- 
drawal requires  so  much  traction  that  extensive  laceration  of  the  urethra  is 
liable  to  result,  the  patient  should  be  put  in  the  lithotomy  position  and  the 
body  removed  through  a  perineal  or  penile  incision  carried  down  to  it  in  the 
middle  line.  The  resulting  wound  is  closed  by  a  buried  catgut  suture  including 
the  urethra  and  its  fibrous  investment,  but  not  the  epithelial  layer  of  the  mucous 
membrane,  and  skin  stitches  of  silkworm-gut  or  silk. 

Special  manipulations  may  be  serviceable  in  certain  cases.  Thus,  should 
the  foreign  body  be  a  gum  catheter,  a  lead-pencil,  or  other  non-metallic  body, 
and  should  the  forceps  fail  to  grasp  it,  ordinary  round-pointed  sewing  needles 
may  be  driven  into  it  through  the  urethra,  and  by  means  of  these,  the  elasticity 
of  the  urethral  walls  allowing  some  play  to  the  needles,  the  foreign  body  grad- 
ually may  be  brought  to  the  meatus. 

A  pin,  nearly  always"  introduced  head  first,  may  be  extracted  by  driving  its 
point  through  the  urethral  walls,  thus  rendering  it  easy  to  seize  the  head  in 
the  forceps  within  the  urethra. 

URETHRAL  CALCULI 

Exceptionally  calculi  are  formed  within  the  urethra,  in  which  case  they  are 
phosphatic.  Usually  they  come  from  the  kidney  or  the  bladder,  and,  though 
apparently  phosphatic  from  incrustation,  show  a  uric  acid  nucleus.  They  are 
most  frequently  observed  in  infancy  and  past  middle  age.  Their  common  seats 
are  the  bulbomembranous  and  prostatic  regions  and  the  navicular  fossa. 
Calculi  rarely  form  spontaneously  in  the  urethra  behind  a  stricture,  the  stag- 
nation not  being  sufficient  to  allow  of  this;  it  is  in  urethral  pouches  or  diver- 
ticula, or  in  the  suppurating  blind  pouches  resulting  from  glandular 
inflammation  complicating  urethritis,  that  calculous  formation  most  frequently 
takes  place. 


SURGERY  OF  THE  URETHRA 


165 


The  direction  of  growth  from  incrustation  is  dependent  upon  the  pressure 
exerted  by  the  urethral  walls.  The  layers  of  lime  salt  are  so  deposited  as  a 
result  of  this  pressure  that  the  growth  is  backward.  As  the  calculi  increase  in 
length  they  are  liable  to  be  segmented  by  fracture;  hence  in  many  cases  several 


Fig.  97. — Urethral  calculi  showing  segmentation. 


calculi  are  found  placed  in  line  and  articulating  with  one  another  (Fig.  97). 
Prostatic  calculi  growing  backward  encounter  much  peripheral  resistance  in 
the  region  of  the  vesical  neck.    Having  passed  this,  there  is  nothing  to  prevent 


Fig.  98. — Urethral  calculi  showing  mushroom  shape.     Cross-sections  to  exhibit 
lamination. 

their  extension  in  all  directions;  hence  these  calculi  often  exhibit  two  nodules 
connected  by  a  narrow  bar  (Fig.  98). 

The  growing  calculus  may  cause  great  dilatation  of  the  infantile  urethra. 
In  adults  ulceration  is  more  common,  the  calculus  escaping  into  the  periurethral 
tissues,  and  sometimes  in  this  position  attaining  great  size  before  it  reaches 
the  surfaces  or  causes  inflammation  or  urinary  infiltration  sufficiently  serious 


166  GENITO-URINARY  SURGERY 

to  require  operation.  Usually  the  ulcerating  cavities  in  which  these  calculi  lie 
open  externally.  In  about  twenty  per  cent,  of  cases  urinary  infiltration  occurs. 
A  calculus  which  has  thus  left  the  urethra,  and  which  lies  in  a  cavity  which 
communicates  with  the  latter  only  by  a  narrow  opening,  cannot  be  detected 
by  the  passage  of  urethral  instruments. 

Symptoms. — Calculi  which  form  in  the  urethra  give  no  other  symptoms  than 
those  due  to  the  inflammation  and  gradually  increasing  obstruction;  i.e.,  urethral 
discharge  and  increased  frequency  of  urination  followed  by  dysuria.  Impacted 
calculi  from  above  occur  in  those  who  have  passed  gravel  or  have  had  attacks 
of  nephritic  colic.  In  children  these  symptoms  are  generally  absent.  The 
lodgement  of  the  stone  occurs  during  urination.  There  is  sudden  partial  or 
complete  stoppage  of  the  stream,  with  the  sensation  of  a  solid  body  having 
lodged  in  the  urethra.  This  is  followed  by  the  symptoms  of  foreign  body  in 
the  urethra  (see  p.  162).    The  X-ray  gives  positive  information. 

Diagnosis. — Given  the  sudden  stoppage  of  the  stream  during  urination  and 
the  sensation  of  a  foreign  body  having  slipped  into  the  urethra,  with  a  precedent 
lithuric  history,  the  diagnosis  is  reasonably  certain.  It  is  further  confirmed  by 
palpation  of  the  urethra,  which  may  show  a  hard  body,  but  more  commonly 
elicits  only  localized  tenderness,  and  by  the  use  of  the  urethroscope.  In  the 
absence  of  the  urethroscope  a  small  metal  sound  should  be  employed;  this  in 
striking  the  stone  gives  a  click  showing  the  position  and  nature  of  the  obstruc- 
tion, or,  this  failing,  rectal  examination  may  enable  the  stone  to  be  felt  lying 
between  the  finger  and  the  sound.  Stones  lying  in  diverticula  or  in  periurethral 
abscesses  can  usually  be  detected  only  by  palpation. 

The  consequences  of  the  impaction  of  stone  in  the  urethra  are  not  often 
serious.  In  cases  of  stricture  with  damaged  kidneys,  complete  retention,  if  not 
promptly  relieved,  may  have  disastrous  consequences.  The  symptoms  of 
impaction  are,  however,  so  marked  that  treatment  is  promptly  instituted;  hence 
there  is  little  chance  for  grave  systemic  disturbances.  Stones  which  have 
ulcerated  through  the  urethral  walls  always  expose  the  patient  to  the  danger  of 
urinary  infiltration. 

Treatment. — The  treatment  is  practically  the  same  as  in  the  case  of  foreign 
bodies.  Immxediate  removal  of  the  stone  is  the  prominent  indication.  If  it  is 
situated  at  or  near  the  navicular  fossa,  meatotomy  may  be  required.  Calculi 
in  the  prostatomembranous  urethra  which  cannot  be  grasped  readily  by  forceps, 
or  which,  if  grasped  and  drawn  upon,  show  such  resistance  that  extensive  lacera- 
tion of  the  urethra  is  certain  to  occur,  should  be  pushed  into  the  bladder  by  a 
bougie,  and  then  crushed  and  evacuated.  If  this  pushing  back  into  the  bladder 
requires  force,  they  should  be  cut  down  upon  and  removed,  the  urethra  and 
wound  being  closed  by  buried  sutures.  Calculi  in  any  part  of  the  urethra  which 
are  firmly  embedded  should  be  treated  in  a  similar  manner.  When  the  calculus 
lies  behind  a  stricture,  this  should  be  divided  by  internal  urethrotomy  if  it 
lies  anterior  to  the  bulb,  by  external  urethrotomy  if  it  is  bulbomembranous,  the 
stone  then  being  removed  either  through  the  meatus  by  forceps  or  through  the 
perineal  wound.  Stones  lying  in  extraurethral  abscesses  should  be  removed  by 
incision,  the  opening  into  the  urethra  being  freshened  and  closed  by  catgut  sutures 
and  the  abscess-cavity  being  drained  by  packing. 


SURGERY  OF  THE  URETHRA  167 

FISTULA  OF  THE  URETHRA 

Fistula  of  the  urethra  is  an  abnormal  opening  through  which  the  urine 
escapes  from  this  canal,  either  into  the  rectum,  the  vagina,  or  externally.  Wery 
exceptionally  these  fistulae  are  congenital,  and  are  due  to  the  establishment  of 
the  function  of  the  kidney  before  the  urethral  canal  is  fully  formed. 

The  usual  cause  of  urethral  fistula  is  slow  leakage  of  urine  incident  to. 
ulceration  behind  a  stricture,  though  suppurative  folUculitis  and  periurethral 
abscess  occurring  in  the  course  of  acute  or  chronic  gonorrhoea,  the  lodgement  of 
a  stone  or  of  a  foreign  body,  or  rupture  or  wound  of  the  urethra  may  result  in 
fistula  formation. 

In  accordance  with  the  position  of  the  opening  and  course  of  the  tract  the 
fistula  is  named  urethrorectal,  urethroperineoscrotal,  urethropenile,  or  urethro- 
vaginal. 

Urethrorectal  fistulae  of  the  noncongenital  varieties  are  due  to  rectal 
trauma  inflicted  in  the  course  of  perineal  operations,  particularly  prostatectomy, 
or  to  the  slow  backward  extension  of  prostatic  abscess,  the  ulceration  ultimately 
reaching  and  destroying  the  rectal  wall,  and  forming  a  small  opening,  except 
in  cases  of  acute  inflammation.  Tuberculous  or  mahgnant  infiltration,  whether 
primary  in  the  urethra  or  in  the  rectum,  often  causes  the  tissues  lying  between 
to  break  down. 

Finally,  a  foreign  body  or  calculus  long  retained  in  the  prostatic  urethra 
may  produce  urethrorectal  fistula.  In  such  cases  the  urethral  opening  is  usually 
small,  and  is  generally  in  the  prostatic  portion  of  the  canal,  at  the  side  of  the 
verumontanum,  the  course  of  the  fistula  being  obliquely  downward  and  back- 
ward. In  addition  to  the  rectal  opening  there  is  often  a  tract  opening  into  the 
perineum.  Other  tracts  may  form,  passing  back  to  the  perineum  and  to  the 
ischiorectal  region,  or  through  the  great  sacrosciatic  foramen  opening  near  the 
hip  joint,  or  upward  on  the  belly- wall. 

The  fistulous  tract  forms  a  dense,  cord-like  band,  easily  felt  on  rectal  ex- 
amination, when  there  is  not  much  infiltration  of  surrounding  tissues.  The 
opening  into  the  rectum  is  placed  within  the  sphincter,  and  may  be  so  small 
and  so  well  covered  by  rectal  folds  that  the  finding  of  it  is  difficult;  in  malignant 
and  tuberculous  cases  it  is  marked  by  a  button  of  exuberant  granulations. 
Following  large,  rapidly  extending  abscess  of  the  prostate  there  is  decided  loss 
of  substance,  the  opening  then  being  of  considerable  size.  The  contact  of  the 
urine  often  produces  an  inflammatory  condition  not  only  of  the  rectal  mucosa 
but  also  of  the  skin  surrounding  the  anus. 

Symptoms. — Pathognomonic  symptoms  of  urethrorectal  fistula  are  the  pas- 
sage of  urine  by  the  rectum  and  exceptionally  the  escape  of  gas  and  of  faces 
through  the  urethra. 

The  quantity  of  urine  passing  into  the  rectum  varies  in  accordance  with  the 
size  of  the  fistula.  When  the  urethra  is  not  obstructed,  but  a  few  drops  escape 
in  this  direction.  These  usually  appear  externally  during  or  immediately  after 
urination,  though  sometimes  the  urine  is  retained  and  is  discharged  by  the 
motions  of  defecation,  exactly  as  would  be  a  liquid  stool.  Gas  and  faeces  may 
escape  from  the  urethra  either  during  or  after  defecation. 


168  GENITO-URINARY  SURGERY 

On  rectal  examination  the  nodular  induration  characteristic  of  a  fistula  is 
easily  detected.  By  means  of  a  speculum  the  opening  of  this  tract  can  be  found 
and  a  probe  can  be  passed  through  it,  encountering  the  surface  of  a  sound  passed 
through  the  urethra  and  into  the  bladder.  The  urethral  orifice  can  sometimes 
be  detected  by  urethroscopic  examination,  and  positive  diagnosis  may  be  made 
by  forcing  a  colored  liquid,  such  as  one-tenth  per  cent,  methyl-blue  solution, 
into  the  urethra,  and  noting  whether  or  not  it  can  be  seen  in  the  rectum.  Or 
equally  decisive  is  the  injection  of  hydrogen  peroxide  into  the  rectal  opening  of 
the  fistula,  the  bubbles  due  to  oxidation  then  appearing  in  the  urine. 

Diagnosis. — The  differential  diagnosis  of  urethrorectal  from  vesicorectal 
fistula  is  made  by  cystoscopic  examination  and  by  injection  of  colored  fluids  in 
moderate  quantity  directly  into  the  bladder  with  the  patient  in  the  dorsal 
decubitus.  If  the  fistulous  opening  be  in  the  urethra,  this  solution  will  not 
appear  in  the  rectum  till  the  patient  urinates.  In  urethrorectal  fistula  urine 
usually  escapes  only  during  the  act  of  micturition,  and  the  inflammation  of  both 
the  rectum  and  the  bladder  is  much  less  marked  than  when  the  opening  is 
directly  into  the  latter  viscus. 

Tuberculous  urethrorectal  fistulae  are  associated  with  irregularly  nodulated 
prostates  and  usually  with  infiltration  and  nodulation  of  one  or  both  seminal 
vesicles,  with  great  thickening  of  the  tissue  lying  between  these  two  pouches; 
tuberculous  cystitis  and  epididymitis  are  often  present.  Urethrorectal  fistulae 
occur  in  malignant  disease  only  when  the  infiltration  is  so  well  marked  as  to 
be  practically  unmistakable. 

Prognosis. — ^The  prognosis  of  urethrorectal  fistula  in  tuberculous  and  can- 
cerous cases  is  hopeless;  even  in  simple  ulceration,  if  there  has  been  much 
destruction  of  tissue,  the  chances  of  ultimate  cure  are  extremely  slight.  If 
the  fistula  is  small  it  may  heal  spontaneously,  especially  after  the  relief  of 
urethral  obstruction,  which  has  tended  to  keep  it  open.  The  consequences  of 
an  uncured  fistula  of  this  kind  are  usually  grave,  since  both  the  rectum  and 
the  bladder  become  chronically  inflamed,  and  are  subject  to  the  immediate 
and  remote  complications  incident  to  such  inflammation. 

Treatment. — Spontaneous  cure  may  take  place  after  fistulaformation  result- 
ing from  suppuration  of  a  prostatic  gland.  This  is  rare.  The  most  important 
point  in  treatment  is  to  remove  obstruction  from  the  urethra.  Although 
stricture  is  not  a  common  cause  of  this  form  of  fistula,  when  once  the  abnormal 
opening  is  formed  a  very  slight  urethral  narrowing  may  be  sufficient  to  keep 
it  open  indefinitely. 

If  restoration  of  the  urethral  canal  to  its  normal  calibre  is  not  followed 
by  cure  of  the  fistula,  the  tract  of  the  latter  should  be  protected  from  the 
irritation  incident  to  the  passage  of  urine  and  faeces  by  regular  catheterization, 
or,  better  still,  continuous  catheterization  kept  up  for  several  weeks,  and  by 
the  checking  of  diarrhoea  and  over-stretching  of  the  rectal  sphincter.  Perineal 
and  ischiorectal  tracts,  together  with  their  diverticula,  should  be  opened,, 
curetted,  and  forced  to  heal  from  the  bottom  by  packing. 

The  fistula  still  remaining  open,  repeated  cauterizations  of  the  rectal  orifice 
and  of  the  whole  tract  by  a  stick  of  copper  sulphate  or  silver  nitrate,  or  by 
the  galvano-cautery,  may  be  tried,  but  will  succeed  only  in  case  the  suppurating 
canal  is  very  small. 


SURGERY  OF  THE  URETHRA  169 

These  means  having  failed,  a  curved  incision  is  made  across  the  perineum 
in  front  of  the  anus,  this  orifice  lying  in  the  concavity  of  the  curve.  This 
incision,  identical  with  that  employed  for  exposing  the  prostate,  is  deepened 
till  the  rectal  and  urethral  orifices  of  the  fistula  are  exposed  and  made  accessible. 
In  this  dissection  a  finger  introduced  into  the  bowel  and  a  sound  passed  through 
the  urethra  into  the  bladder  will  enable  the  surgeon  to  avoid  w^ounding  either 
of  these  structures.  The  two  orifices  having  been  exposed,  and  the  main  tract 
and  its  diverticula  having  been  opened,  dissected  out,  the  edges  of  each  fistulous 
opening  are  denuded  and  closed  by  catgut  suture  introduced  as  in  the  closing 
of  vesicovaginal  fistula.  When  the  tract  is  small  and  fairly  direct  and  the 
surrounding  tissues  are  healthy,  the  perineal  wound  may  be  closed  by  buried 
catgut  sutures.  When  there  is  wide  infiltration  the  wound  should  be  packed 
and  allowed  to  heal  from  the  bottom. 

MaHgnant  fistulse  are  not  helped  by  this  operation. 

Urethroperineoscrotal  Fistula. — This  fistula,  by  far  the  commonest  of 
all,  is  usually  due  to  ulceration  behind  a  stricture,  though  traumatism,  erosion 
by  stone  or  foreign  body,  acute  abscess,  ulceration  extending  from  caries  or 
necrosis  of  the  pelvis,  or  tuberculous  or  gummatous  infiltration,  may  occasionally 
cause  it.  The  urethral  orifice  is  generally  single,  but  externally  there  may  be  sev- 
eral openings,  due  to  the  fact  that  the  one  first  formed  has  a  tendency  to  con- 
tract slowly,  thus  obstructing  the  flow  of  urine,  which  then  burrows  in  various 
directions.  In  cases  of  urinary  extravasation  from  traumatism  several  fistulae 
may  be  formed  at  the  same  time. 

Occasionally  the  cutaneous  orifices  of  the  fistula  are  placed  well  back  on 
the  buttocks,  down  the  thighs,  in  the  region  of  the  hip,  or  in  the  belly-wall, 
though  usually  they  are  found  in  the  perineum  and  scrotum.  The  fistulae 
form  dense  fibrous  tracts  easily  detected  by  palpation.  Some  of  these  tracts  end 
in  blind  pouches.  They  are  lined  by  unhealthy  granulations,  rarely  by  epi- 
thelium. Occasionally  calculi  are  formed  in  their  interior,  or  their  walls  become 
incrusted  with  urinary  salts.  The  skin  and  subcutaneous  tissue  of  the  scrotum 
and  perineum  may  be  enormously  thickened,  producing  a  condition  much  like. 
elephantiasis.  Large  fibrous  nodules  of  partially  organized  inflammatory  tissue 
may  form  about  the  fistulous  orifices. 

Diagnosis. — The  diagnosis  is  made  by  the  escape  of  urine  from  the  surface 
openings  of  the  fistula.  When  the  openings  are  so  small  that  little  or  no  urine 
escapes  the  diagnosis  may  sometimes  be  established  by  holding  the  meatus  shut 
during  urination,  or  by  injecting  hydrogen  peroxide  or  a  colored  solution  into 
the  urethra  with  a  syringe. 

The  differential  diagnosis  between  urethroperineal  and  perineoanal  fistula 
is  founded  on  the  history  of  the  case,  and  the  results  of  examination  with  a 
probe  and  by  the  injection  of  solutions.  Exceptionally  there  are  openings  into 
both  the  urethra  and  the  rectum. 

Sinuses  dependent  upon  chronic  suppuration  of  Cowper's  glands  or  of  the 
urethral  glands  can  be  diagnosed  from  fistulae  only  by  the  absence  of  urine 
leakage  and  the  negative  results  of  pressure  injections. 

Treatment. — The  formation  of  these  fistulae  may  be  prevented  by  prompt 
suture  of  the  urethra  in  case  the  canal  is  ruptured  or  wounded  either  surgically 


170 


GEXITO-URIXARY  SURGERY 


or  accidentally;  by  the  immediate  evacuation  and  packing  of  glandular  and 
periglandular  urethral  abscesses,  followed  by  continuous  catheterization;  and 
by  the  dilatation  of  strictures  before  they  give  obstructive  symptoms. 

A  perineoscrotal  fistula  having  formed,  complete  restoration  of  the  urethra 
to  its  normal  calibre  is  the  first  essential  in  successful  treatment.  The  partial 
cure  of  stricture  is  in  these  cases  unavailing.  Usually  when  the  calibre  of  the 
urethra  is  carried  up  to  the  point  indicated  in  the  scale  given  on  page  257,  the 
fistula,  unless  its  walls  are  too  densely  indurated  or  have  been  covered  with 
pavement  epithelium,  will  heal  spontaneously.  At  times  continuous  catheteriza- 
tion, supplemented  by  cleansing  and  stimulating  the  fistulous  tracts,  will  accom- 
plish a  cure. 

The  most  satisfactory  method. of  treatment,  after  having  brought  the  urethra 
to  full  calibre,  is  by  external  urethrotomy,  -with  a  curettement  or  excision  of 
the  fistulous  tracts,  including  the  removal  of  all  fibrous 
nodules.  If  a  catheter  is  well  tolerated,  continuous  cathe- 
terization should  be  maintained  for  tw'o  or  three  weeks. 
Urethropenile  fistula  is  usually  encountered  as  a 
short,  straight,  single,  nonindurated  channel,  lined  with 
pavement  epithelium,  passing  by  the  shortest  route  from 
the  urethra  to  the  surface,  though  exceptionally  when 
urinary  extravasation  has  taken  place  from  the  midpenile 
portion  of  the  urethra,  it  may  form  a  subcutaneous  tract, 
running  parallel  with  the  course  of  the  urethra  and  open- 
ing just  behind  the  glans.  Or  the  fistulous  tract  ma}'- 
pass  backward  and  open  near  the  root  of  the  penis. 

Treatment . — The  restoration  of  the  normal  calibre  of 
the  urethra  anterior  to  the  fistula  is  the  first  essential  of 
treatment,  and  will  often  be  curative. 

If  the  fistula  persists,  regular  evacuation  of  the  blad- 
der by  means  of  a  catheter  should  be  continued  for  a 
week,  the  urethra  receiving  an  antiseptic  flushing  (boric 
acid  four  per  cent.,  or  silver  nitrate  1  to  10,000)  after 
each  passage  of  the  instrument.  If  this  fails,  and  if  the  fistula  is  direct  and 
of  small  size,  cauterization  of  the  tract  by  the  galvano-cautery  may  cure.  This 
failing,  the  urethra  should  be  thoroughly  freed  about  the  margins  of  the  opening, 
and  the  borders  of  the  latter  having  been  freshened  should  be  approximated  by 
a  row  of  catgut  sutures  (Fig.  99);  another  row  of  silk  sutures  is  employed  to 
bring  together  the  skin  and  underhing  fascia.  The  dilating  speculum  or  urethral 
dilator  greatly  facilitates  this  operation.  Undue  tension  on  the  sutures  and 
contamination  by  urine  may  be  prevented  by  regular  catheterization,  or  still 
more  surely  by  perineal  urethrostomy,  the  bladder  being  drained  through  this 
opening  till  the  fistula  is  permanently  closed. 

If  the  fistula  is  so  large  that  closure  by  this  operation  would  entail  too 
great  an  encroachment  on  the  urethral  calibre,  a  plastic  operation  wall  be 
required.  A  transplanted  flap  is  usually  taken  from  the  scrotum;  or  one  from 
the  prepuce  or  from  the  inguinal  or  abdominal  region  may  be  employed.  \Mien 
the  flap  is  taken  from  the  scrotum,  a  quadrilateral  space  about  the  fistulous 


Fig.  99. — Closure  of  fistula. 


SURGERY  OF  THE  URETHRA  171 

opening  is  freshened,  a  flap  of  similar  shape,  with  its  adherent  base  down, 
is  raised  from  the  scrotum,  and  its  anterior  and  lateral  borders  are  sutured  to 
the  freshened  surfaces.  In  a  week  the  pedicle  is  divided  and  secured  to  the 
posterior  border  of  the  defect.  To  secure  success  in  these  cases,  regular  cathe- 
terization or  perineal  urethrostomy  is  necessary. 

Probably  the  most  efficient  way  of  closing  these  fistulse  is  by  the  operation 
of  double  lateral  flaps.  A  short  flap  is  turned  in,  bringing  the  skin  surface 
toward  the  urethra;  then  a  long  flap,  from  the  opposite  side,  so  freely  dissected 
that  it  is  subject  to  very  little  tension,  is  brought  across  by  sutures,  its  raw  sur- 
face being  apposed  to  the  raw  surface  of  the  inverted  short  flap. 

URETHRAL  POUCHES  OR  DIVERTICULA 

In  addition  to  the  congenital  pouches  already  described,  there  are  observed 
sacculations  at  the  expense  of  the  urethral  wall,  due  either  to  gradual  yielding 
to  vesical  pressure  or,  more  commonly,  to  ulceration  and  abscess-formation,  or 
to  both  these  causes  combined.  The  predisposing  factor  is  inflammation  incident 
to  stricture,  especially  when  there  is  a  calculus  lodged  behind  the  stricture. 

Symptoms. — The  symptoms  are  sufficiently  characteristic.  There  is-  long- 
continued  dribbling  of  urine  after  apparent  complete  evacuation  of  the  bladder. 
Examination  shows  either  a  sacculation  or  a  dilatation  in  the  course  of  the 
urethra,  which  is  distended  during  the  course  of  micturition,  and  which  on 
being  compressed  becomes  flaccid,  urine  at  the  same  time  dribbling  from  the 
meatus.  In  some  cases,  when  the  pouch  contains  a  calculus,  the  latter  changes 
position  during  urination,  acting  as  a  valve.  Usually  there  are  no  inflammatory 
phenomena,  and  the  tumor  is  compressible  and  painless,  thus  differing  from 
chronic  urinary  abscess.    Urethroscopy  is  the  most  satisfactory  diagnostic  method. 

Treatment . — Treatment  consists  in  extracting  the  calculus,  if  there  is  one, 
either  by  intraurethral  manipulations  or  by  external  incision.  Strictures  should 
be  cured  by  gradual  dilatation,  or  by  urethrotomy,  with  perineal  resection  of 
the  sac-walls  if  necessary.  '  Simple  diverticula  behind  the  stricture  are  usually 
cured  by  wide  dilatation.  Exceptionally  after  cure  of  stricture  the  pouch  must 
be  resected  and  the  opening  into  the  urethra  closed  by  suture. 

URETHRAL  NEOPLASMS 

Papillomata  (which  the  urethroscope  has  shown  to  be  not  so  rare  as  was 
believed)  appear  as  pedunculated  or  sessile,  '.ascular,  papillary  outcroppings 
(Fig.  100);  other  neoplasrris  of  less  frequent  occurrence  are  cysts,  polyps,  and 
carcinomata.  They  grow  from  any  portion  of  the  canal,  but  are  commonly 
found  in  the  navicular  fossa  and  behind  strictured  portions  of  the  urethra, 
syringing  from  the  floor.  They  are  usually  small,  but  exceptionally  may  attain 
a  size  sufficient  to  obstruct  very  considerably  the  stream  of  urine. 

When  they  develop  near  the  meatus,  and  this  is  their  commonest  seat,  they 
are  prone  to  grow  outward,  projecting  from  the  urethral  orifice  as  a  soft,  easily 
bleeding,  fungating  mass. 

Symptoms. — These  are  usually  slight,  and  are  mostly  mistaken  for  those  of 
gleet  dependent  upon  stricture.  There  is  a  thin,  muco-purulent  discharge,  with 
slight  burning  during  urination,  and,  if  the  growth  attains  large  size,  interference 


172 


GENITO-URINARY  SURGERY 


with  the  volume  and  force  of  the  stream.  Often  there  is  free  bleeding  on 
instrumentation,  particularly  in  cases  characterized  by  comparatively  large 
areas  of  sessile,  highly  vascular  papillary  hypertrophy.  The  diagnosis  is  founded 
on  an  intraurethral  examination.  The  .urethroscope  shows  these  growths  usually 
as  slight  villous  projections,  sometimes  as  raspberry-like  masses,  occasionally  as 
gelatinous  pyriform  tumors. 

Treatment. — This  consists  in  removal  of  the  growth  by  means  of  high- 
frequency  desiccation,  wire  snare,  curette,  or  galvanocautery,  manipulated 
through  an  endoscopic  tube.  If  the  pol)qD  is  snared  or  scraped  away,  the 
place  from  which  it  was  removed  should  be  touched  with  glacial  acetic  acid  or 
pure  carbolic  acid.  This  operation  is  not  difficult  when  the  growths,  as  is 
usually  the  case,  are  situated  near  the  meatus.  A  dilating  speculum  in  these 
cases  is  more  serviceable  than  the  closed  tube. 

Urethral  caruncles  are  rare  in  the  male  urethra,  but  are  occasionally  found 


Fig.    100. — Papilloma   of   the  urethra,      b,   side   view   of   the  growth. 
(Voillemier.) 


near  the  orifice  in  the  navicular  fossa.  They  consist  of  small,  bright,  red, 
pedunculated,  highly  vascular,  papillated  tumors,  made  up  of  connective  tissue, 
covered  by  stratified  epithelium. 

They  are  characterized  by  severe  pain,  aggravated  by  urination,  and  moder- 
ate mucopurulent,  often  blood-stained,  discharge.  The  pain  during  sexual 
intercourse  is  so  great  as  to  be  inhibitory.    Instrumentation  is  intolerable. 

They  are  distinguished  from  irritable  gonorrha:a  by  the  gradual  onset,  and 
by  the  absence  of  gonococci  from  the  discharge.  The  urethroscope  discloses 
the  tumor. 

The  treatment  consists  in  the  complete  removal  of  the  little  tumor — includ- 
ing its  base — by  means  of  small  scissors,  the  wire  ecraseur,  or-  cautery  knife. 
A  meatus  dilator  will  usually  make  the  growth  accessible,  though  a  preliminary 
meatotomy  may  be  needful. 


SURGERY  OF  THE  URETHRA  173 

Cancer  of  the  Urethra. — Primary  cancer  of  the  urethra  occurs  in  men 
over  lifty  years  of  age  who  have  suffered  from  chronic  urethritis  due  to  stricture. 
It  has  been  found  only  in  the  bulbous  and  membranous  urethra.  The  growth 
invariably  proceeds  forward  (Hall),  showing  no  tendency  to  invade  the  prostate 
and  the  tissues  behind  the  triangular  ligament. 

Symptoms. — The  symptoms,  during  the  early  stage  of  infiltration,  are 
simply  those  of  chronic  urethritis;  later  there  may  be  increasing  difficulty  in 
urinating,  obstruction  to  the  passage  of  a  catheter,  and  the  formation  of  rapidly 
growing  infiltrations,  which,  in  the  absence  of  previously  existing  fistula,  soften 
in  one  or  more  spots  and  rupture,  discharging  pus,  blood,  and  often  very  offensive 
urine.  After  rupture  there  is  found  a  comparatively  small  cavity, with  hard, 
irregular  walls  tending  to  fungate  in  places. 

Diagnosis. — The  diagnosis  is  based  upon  the  urethroscopic  appearance,  the 
dense  infiltration,  the  progressive  and  rapid  growth,  and  the  removal  and 
microscopical  examination  of  a  portion  of  the  tumor.  The  tendency,  to  bleed 
and  fungate  and  enlargement  of  the  inguinal  lymphatics  may  possibly  prove 
of  diagnostic  value. 

Owing  to  delay  in  diagnosis  few  cases  of  cancer  of  the  urethra  have  so  far 
been  saved.  In  the  future  earlier  diagnosis  through  use  of  the  urethroscope 
should  produce  a  higher  percentage  of  operative  cures. 

Cancer  of  Cowper's  gland,  which  on  first  examination  may  suggest  primary 
cancer  of  the  urethra,  may  be  distinguished  from  the  latter  by  the  fact  that  it 
has  at  first  a  tendency  to  grow  towards  the  skin  and  rectum  rather  than  in 
the  direction  of  the  urethra,  forming  a  palpable  perineal  tumor,  which,  till  it 
has  reached  a  large  size,  does  not  interfere  with  the  passage  of  a  catheter  or 
the  free  flow  of  the  urine. 

Treatment. — Immediate  and  complete  removal  of  all  the  diseased  parts  and 
of  the  anatomically  associated  glands  is  indicated.  Where  this  is  not  possible, 
irrigations,  local  washings,  and  morphine  in  sufficient  doses  to  quiet  the  patient 
should  be  employed. 

DISEASES  OF  COWPER'S  GLANDS 

On  each  side  of  the  membranous  urethra,  between  the  two  layers  of  the 
triangular  ligament,  is  placed  a  pea-sized,  lobulated,  racemose  gland,  the  duct 
of  which,  one  inch  long,  perforates  the  anterior  layer  of  the  triangular  ligament 
and  empties  into  the  bulbous  urethra.  These  glands  are  sexual  in  function, 
and  their  secretion  forms  a  part  of  the  semen.  Both  they  and  their  ducts,  being 
lined  by  columnar  epithelium,  are  readily  susceptible  to  gonorrhceal  invasion, 
and  once  having  been  infected  remain  fruitful  sources  of  reinfection  after  an 
apparently  cured  urethritis.  These  structures  cannot  be  reached  by  intra- 
urethral  applications,  nor  are  they  amenable,  because  of  their  position,  tc 
massage.  Chronic  hypersecretion  of  Cowper's  glands  is  a  common  source  of  in- 
tractable urethrorrhcea.  As  is  the  case  with  their  homologues  (Bartholin's 
glands),  these  structures  are  rarely  infected  by  organisms  other  than  the 
gonococcus. 

Cowperitis. — Cowperitis,  or  inflammation  of  Cowper's  gland,  usually  de- 
velops in  the  third  or  fourth  week  of  an  acute  urethritis.     It  is  due  to  an 


174  GENITO-URINARY  SURGERY 

extension  of  the  disease  from  the  bulbous  urethra,  into  which  the  ducts  of 
these  glands  empty.  All  the  causes  which  tend  to  aggravate  an  attack  of  acute 
urethritis,  such  as  sexual  or  alcoholic  excesses  or  violent  exercise,  predispose 
to  inflammation  of  Cowper's  glands. 

Symptoms. — The  first  symptom  is  a  sticking  pain  in  the  perineum;  this  is 
greatly  increased  by  pressure,  so  that  sitting  or  vv^alking  markedly  increases  the 
suffering.  The  swelling  of  the  glands  is  resisted  by  the  two  layers  of  the 
triangular  ligament  between  which  they  are  situated  and  by  the  deep  perineal 
fascia:    hence,  as  the  inflammation  progresses,  great  tension  is  developed. 

Both  micturition  and  defecation  are  painful,  the  suffering  being  particularly 
severe  at  the  termination  of  the  former  act,  since  the  transverse  fibres  of  the 
compressor  urethrae  muscle,  as  they  contract  to  expel  the  last  drops  of  urine, 
compress  the  inflamed  and  swollen  gland.  If  the  swelling  is  very  marked  there 
will  be  some  difficulty  in  micturition  from  mechanical  pressure. 

Usually  but  one  gland  is  involved.  It  may  then  be  felt  as  a  small,  hard, 
very  tender  tumor  situated  just  behind  the  bulb, — that  is,  about  the  middle 
of  the  perineum.  This  tumor  may  be  recognized  by  deep  palpation  of  the 
perineum,  or  by  pressure  made  in  an  upward  and  forward  direction  by  a  finger 
inserted  just  within  the  external  sphincter.  The  fact  that  this  swelling  is 
on  one  side  of  the  median  line  constitutes  a  distinct  diagnostic  point.  When 
both  glands  are  involved  the  swelling  is  bilateral. 

Suppuration  sometimes  occurs.  When  this  involves  the  periglandular  tissues 
the  skin  will  become  reddened  and  oedematous,  and  the  rigors,  fever,  and  throb- 
bing pains  of  pus-formation  will  be  present.  The  swelling  in  these  cases  is 
nearly  always  sufficient  to  interfere  materially  with  micturition,  often  causing 
complete  retention.  The  abscess  usually  perforates  externally,  and  on  the  dis- 
charge of  a  large  quantity  of  pus  heals  kindly,  although  subsequently  it  may 
be  followed  by  troublesome  cicatricial  contraction.  In  rare  instances  the 
abscess  may  perforate  into  the  urethra,  but  even  then  extravasation  of  urine 
is  exceptional.  The  inflammation  frequently  becomes  chronic,  lingering  par- 
ticularly in  the  gland  ducts,  and  occasioning  a  discharge  which  is  extremely 
hard  to  cure. 

During  the  course  of  an  acute  cowperitis  the  discharge  of  the  anterior 
urethritis  usually  ceases  or  is  greatly  diminished  in  quantity. 

Diagnosis. — When  the  case  is  seen  early  the  anatomical  position  of  the 
firm  nodule  or  nodules  renders  diagnosis  easy;  but  when  suppuration  occurs, 
together  with  wide-spread  periadenitis,  it  may  be  hard  to  determine  the  true 
nature  of  the  inflammation. 

It  may  be  distinguished  from  a  superficial  perineal  abscess  by  the  fact  that 
the  latter  cannot  cause  dysuria. 

From  urinary  infiltration  following  stricture  it  can  be  distinguished  only 
by  the  history  of  the  case.  Periurethral  abscess  of  the  bulb  is  farther  forward 
than  is  the  tumor  in  cowperitis,  and  is  always  in  the  median  line. 

Treatment. — Every  effort  should  be  made  to  lessen  the  urethral  inflamma- 
tion. Strong  antiseptic  or  astringent  injections  or  intraurethral  manipulation 
must  be  discontinued  at  once.  Rest  in  bed,  prolonged  hot  baths,  and  the 
administration  of  a  laxative  or  a  saline  purge  are  always  indicated.     A  hot- 


SURGERY  OF  THE  URETHRA  175 

water  bag  applied  to  the  perineum  relieves  pain  and  seems  to  lessen  the  ten- 
dency to  abscess  formation.  When  the  suffering  is  intense,  hypodermics  of 
morphine  are  indicated. 

When  throbbing  pain,  oedema,  fiunctuation,  and  rigors  and  fever  show  that 
pus  has  formed,  the  abscess  should  be  cut  into  at  once,  and  its  cavity  curetted 
and  packed  with  iodoform  gauze.  Urinary  extravasation,  of  course,  demands 
immediate  incision  and  drainage.  Fistulae  may  be  guarded  against  by  permanent 
catheterization  after  the  abscess  has  been  opened  and  drained.  When,  in  spite 
of  every  precaution,  fistulae  form,  and  are  not  relieved  by  catheterization  and 
free  dilatation,  excision  of  the  fistulous  tract,  as  well  as  of  any  remnant  of  the 
gland,  and  suture  of  the  freshened  edges,  are  required. 

Cysts  of  Cowper's  Glands. — These  rare  swelHngs  project  into  the  urethral 
lumen  at  the  expense  of  its  floor.  If  large,  they  may  be  detected  by  perineal 
or  rectal  palpation.  In  one  case  the  tumor  opened  externally,  discharging  a 
viscid  fluid  at  irregular  intervals,  but  particularly  during  and  after  coitus. 

Cancer  of  Cowper's  Glands. — This  rare  growth,  in  the  form  of  a  cylin- 
droma forms  a  hard,  movable,  distinct  encapsulated  nodule.  As  it  grows  it  becomes 
adherent  to  the  surrounding  parts,  and  the  involved  inguinal  glands.  The 
growth,  at  first  painless,  rapidly  increases  in  size  and  ultimately  presses  upon 
the  urethra.  Micturition  becomes  difficult,  frequent,  and  sometimes  painful. 
Defecation  is  interfered  with,  and  sitting  or  walking  increases  suffering. 

Diagnosis. — The  characteristic  feature  of  this  affection  is  the  position  of 
the  tumor.  It  is  placed  upon  the  bulb,  is  at  first  covered  with  healthy  skin, 
and  grows  rapidly.  Combined  rectal  and  perineal  examination  shows  it  to  be 
in  the  position  which  normally  should  be  occupied  by  Cowper's  glands. 

Treatment . — Complete  early  removal.  A  timely  diagnosis  is  rarely  made. 
These  patients  die  within  the  year,  though  there  is  one  recorded  case  of  survival 
without  recurrence  for  nearly  two  years. 


CHAPTER  X 

AFFECTIONS  CHARACTERIZED  BY  URETHRAL 
DISCHARGE 

In  accordance  with  their  etiology,  affections  characterized  by  urethral  dis- 
charge may  be  classified  as  follows: 

1.  Urethrorrhcea.    Entirely  independent  of  local  lesions. 

2.  Traumatic  urethritis,  due  to  (a)  Instrumentation  (6)  Irritating  injec- 
tions, (c)  External  traumatism. 

3.  Irritative  urethritis,  (a)  Ingestive,  due  to  certain  drugs  and  articles  of 
food;  (b)  Diathetic,  dependent  upon  irritating  conditions  of  the  urine  incident 
to  defective  metabolism;  gouty,  rheumatic,  oxaluric,  and  phosphaturic  urethritis; 
(c)  Erethismic,  due  to  repeated  excessive  coitus  or  prolonged  ungratified  sexual 
excitement. 

4.  Eruptive  urethritis  occurs  during  the  course  of  certain  acute  exanthe- 
mata, and  as  a  manifestation  of  urethral  herpes  or  eczema. 

5.  Mechanical  urethritis,  incident  to  (a)  stricture,  (b)  urethral  neoplasms, 
(c)  urinary  calculi,  (d)  animal  parasites  (rarely,  in  children). 

6.  Concomitant  urethritis,  dependent  upon  disease  of  para-  and  periurethral 
structures. 

7.  Infective  urethritis. —  {a)  Simple  pyogenic,  sometimes  called  irritative  or 
abortive  gonorrhoea;  (b)  Gonococcal;  (c)  Syphilitic  (primary,  secondary,  ter- 
tiar>0;  (d)  Chancroidal;  (e)  Tuberculous;  (/)  T\'phoidal;  (g)  Influenzal;  (h) 
Pneumococcic ;    (i)  Diphtheritic. 

Urethrorrhcea  is  due  to  depraved  constitutional  conditions,  and  occurs 
independently  of  local  lesions.  It  is  observed  during  convalescence  from  acute, 
exhausting  diseases,  such  as  typhoid  fever,  scarlet  fever,  pneumonia,  influenza, 
small-pox,  and  the  like;  or  in  the  course  of  such  chronic  affections  as  tubercu- 
losis, cancer,  syphilis,  advanced  nephritis,  neurasthenia,  anaemia,  and  other 
debilitating  cachectic  conditions.  The  discharge  is  dependent  upon  a  relaxed 
and  leaky  mucous  membrane,  and  represents  an  excessive  quantity  of  what  is 
in  character  a  normal  secretion.  This  constitutes  the  sole  symptom,  appearing 
as  a  colorless  viscid  material  not  unlike  glycerin.  In  the  urine  it  forms  long 
shreds. 

Diagnosis. — This  depends  on  the  history,  the  general  physical  examination, 
and  the  elimination  of  other  causes  such  as  catheterization,  etc.  Microscopic 
examination  of  the  discharge  shows  mucus  epithelial  cells,  a  few  leucocytes,  and 
a  variety  of  bacteria  normally  present.     Spermatozoa  are  often  found. 

Treatment  should  be  entirely  constitutional.     Incidentally,  the  urine  should 
be  kept  unirritating.     Local  congestion,  such  as  would  be  caused  by  sexual 
excitement,  stripping  the  urethra,  and  irritating  injections  must  be  avoided. 
Internally,  cubebs  may  be  serviceable. 
176 


AFFECTIONS  CHARACTERIZED  BY   URETHRAL  DISCHARGE   177 

URETHRITIS 

Etiology. — The  predisposing  causes  of  urethritis  are  congestion  and  impaired 
local  vitality.  With  the  more  potent  exciting  causes  it  is  not  essential  that  any 
predisposing  cause  should  be  present/ 

The  exciting  cause  of  urethritis  is  infection,  usually  by  the  gonococcus. 

Pathology. — This  is  similar  to  that  of  inflammation  of  other  mucous  canals, 
with  certain  differences  incident  to  the  anatomy  and  physiology  of  the  urethra, 
its  susceptibility  to  certain  varieties  of  microbic  invasion,  and  its  accessibility 
to  local  treatment. 

The  inflammation  common  to  all  forms  of  the  acute  disease  usually  begins 
at  or  near  the  meatus  and  spreads  backward.  The  mucosa  of  the  canal  and 
of  its  many  follicles  and  lacunae  becomes  infiltrated,  red,  swollen,  covered  with 
a  mucoid,  sanious,  or  purulent  exudate,  and  soon  the  epithelium  exfoliates.  In 
the  milder  cases  the  process  is  limited  to  the  mucosa,  and  after  a  few  days  or 
weeks  subsides,  but  may  persist  in  the  follicles  and  glands  for  weeks  and  months. 

I'he  gonococcus  penetrates  deeply  into  the  submucous  tissue,  causing  abundant 
round-cell  infiltration,  nests  of  which  may  be  the  beginning  of  periurethral 
abscess.  The  process  may  involve  any  or  all  of  the  structures  opening  into  the 
urethra,  including  the  upper  urinary  tract.  Lymphangitis  and  lymphadenitis  are 
common;  phlebitis  and  cellulitis  are  rare. 

Urethroscopic  examination  of  acute  diffuse  urethritis  shows  redness,  swelling, 
and  exfoliation  of  the  mucous  membrane,  and  muco-purulent  exudation. 

Symptomatology.— T)\sc\vdsge  is  the  only  constant  symptom.  It  ma}^  be 
manifest  only  in  the  urine;  it  may  appear  as  a  slight  moisture  at  the  meatus, 
not  noticed  unless  the  intervals  between  urination  are  long,  or  as  a  drop  after 
stripping  the  urethra,  or  during  a  straining  effort  at  defecation.  In  acute  cases 
it  may  appear  as  a  profuse,  continuous  outpour. 

In  character,  it  may  be  thin  and  watery,  viscid,  gelatinous,  and  stringy, 
resembling  the  uncooked  white  of  egg,  milk-and-watery  in  appearance,  or  may 
be  made  up  of  a  thick,  yellowish,  greenish  sanguino-purulent  material.  It  may 
be  noted  in  the  form  of  crusts  where  it  has  dried  around  the  meatus,  or  as 
stains  on  the  underclothing.     It  may  be  without  odor,  or  extremely  foul. 

The  urine  may  be  cloudy,  or  quite  opaque,  depending  on  the  amount  of 
mucus,  pus,  and  blood  contained  in  it;  or  may  exhibit  various  forms  of  urethral 
shreds,  from  the  irregular,  short,  thick,  scaly,  tack,  or  comma-shaped  particles, 
to  long,  translucent,  branching,  gelatinous  threads. 

Pain  may  vary  from  the  slighest  itching,  tickling,  or  burning  sensation  at 
the  meatus  to  constant  harassing  distress  throughout  the  whole  of  the  canal. 
It  may  be  referred  to  the  glans,  the  penis,  the  deep  perineum,  or  may  radiate 
down  the  thighs. 

Alterations  of  function  vary  from  slightly  frequent  urination  to  annoying 
urgency,  associated  with  painful  vesical  and  rectal  tenesmus.  Tenderness  is 
manifested  by  burning  upon  urination,  aching  during  erection,  or  a  stabbing, 
cutting  anguish  during  seminal  emission.  Persistent,  painful  erections,  wath 
nocturnal  pollutions,  and  chordee^  may  occur;  rarely  acute  retention  develops 
12 


178  GENITO-URINARY  SURGERY 

from   reflex   or   voluntary   inhibition    of   the   detrusors   or   contraction   of   the 
sphincter. 

The  objective  signs  may  be  absent;  or  they  may  appear  as  a  simple  florid 
puffiness  of  the  lips  of  the  meatus,  or  may  be  conspicuous  in  the  form  of 
inflammatory  oedema  of  the  glans,  the  prepuce,  and  rarely  the  subcutaneous 
tissue,  with  accompanying  bubo. 

The  mechanical  disturbances  dependent  on  the  swelling  vary;  there  may  be 
slight  difficulty  in  starting  the  stream,  loss  of  force  or  diminution  of  the  normal 
parabohc  curve,  or  dribbling  after  the  act.  Swelling  or  gluing  of  the  lips  of 
the  meatus  may  break  or  deflect  the  stream. 

Traumatic  urethritis  is  usually  due  to  instrumentation  or  to  irritating 
injections.    It  may  be  caused  by  external  traumatism. 

Instrumentation  always  causes  more  or  less  traumatism,  varying  in  degree 
from  slight  contusion  to  laceration,  puncture,  or  even  rupture  of  the  urethra. 

Irritating  injections  causing  urethritis  (of  silver,  mercury,  phenol,  etc.) 
will  usually  have  been  used  to  prevent  or  abort  gonorrhoea. 

The  symptoms  are  commensurate  to  the  severity  of  the  trauma.  Those  of 
the  hv-peracute  type  developing  immediately  and  characterized  by  great  pain, 
rapid  swelHng,  agonizing  ardor  urinse,  or  even  retention  of  urine  and  a  scanty 
discharge  of  bloody  pus  are  practically  always  due  to  irritating  injections. 
Prolonged  or  brutal  catheterization  may  cause  an  intense,  frankly  purulent 
inflammation,  but  of  comparatively  slow  development. 

External  traumatism  can  produce  urethritis  only  by  first  causing  a  sanguine- 
ous effusion  into  the  urethra  and  in  the  periurethral  tissues  as  a  result  of  partial 
or  complete  rupture  of  the  canal.     (See  page  158.) 

Prognosis. — Urethritis  due  to  irritating  injections  is  at  times  distressingly 
persistent  (years),  and  may  lead  ultimately  to  stricture  formation.  Generally 
the  symptoms  disappear  promptly. 

Treatment. — Instrumientation  urethritis  may  be  best  avoided  by  the  skilful 
use  of  clean  instruments,  preceded  by  cleansing  the  glans  and  by  antiseptic 
urethral  flushings.  For  the  avoidance  of  the  urethritis  incident  to  continuous 
catheterization,  see  page  74.  During  the  acute  course  of  an  injection  urethritis, 
in  addition  to  rest  in  bed,  hot  sitz-baths,  diluents  by  the  mouth,  and  opium 
suppositories,  urethral  injections  of  eucaine  and  adrenalin  together  with  evapo- 
rating lotions  applied  to  the  penis  may  be  needed  to  relieve  retention  of  urine 
due  to  inflammatory  swelling.  Urethritis  from  external  traumatism  should  be 
treated  by  irrigation  and  later  by  dilatation. 

Irritative  Urethritis. — Under  this  heading  are  included  Ingestive,  Dia- 
thetic, and  Erethismic  Urethritis. 

Ingestive  urethritis,  characterized  by  scanty  mucoid  discharge  and  slight 
ardor  urinae,  is  occasionally  noted  after  the  ingestion  of  such  substances  as 
asparagus,  rhubarb,  turpentine,  cubebs,  copaiba,  cantharides,  alcohol,  arsenic, 
and  potassium  iodide. 

Diagnosis. — This  is  based  on  the  history,  and  on  the  absence  of  other  causes 
for  urethral  discharge.  The  symptoms  are  mild,  the  duration  of  the  affection 
brief,  and  cure  results  at  once  upon  removal  of  the  cause.  Ardor  urinae  may  be 
more  marked  than  the  inflammatory  symptoms  would  seem  to  warrant.     The 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   179 

discharge  which  follows  the  abuse  of  alcohol  is  not  strictly  ingestive,  but  is 
usually  due  to  the  lighting  up  of  a  latent  lesion  by  the  irritating  condition  of 
the  urine.  When  the  symptoms  are  unduly  prolonged,  a  search  should  be  made 
for  such  lesions. 

Diathetic  urethritis  is  dependent  upon  the  irritating  urine  incident  to  gout, 
rheumatism,  and  the  defective  metabolism  characterized  by  the  habitual  appear- 
ance of  large  quantities  of  oxalates  and  phosphates  in  the  urine.  The  relation 
between  the  joint  manifestations  of  rheumatism  and  gout  and  a  slight  mucoid 
urethral  discharge  has  been  repeatedly  noted;  indeed,  this  discharge  has  been 
observed  occasionally  as  a  manifestation  of  so-called  retrocedent  gout. 

Diagnosis. — This  must  be  based  on  the  history.  The  discharge  is  associated 
with  general  diatetic  errors  rather  than  with  the  ingestion  of  one  or  two  par- 
ticular articles  of  food.  Other  manifestations  of  gout  or  rheumatism  are  present 
and  the  acid  urine  is  highly  concentrated.  The  discharge  is  mucoid  in  character, 
with  an  abundance  of  epithelial  cells,  a  few  leucocytes,  and  no  gonococci. 

Prognosis. — In  the  absence  of  complicating  gonorrhoea!  lesions,  the  urethral 
catarrh  disappears  when  the  constitutional  condition  is  bettered  and  the  urine 
rendered  bland. 

Treatment  is  obvious.  Local  treatment  is  not  indicated.  If,  however,  the 
discharge  persists,  search  should  be  made  for  localized  lesions. 

Oxaluria  and  phosphaturia  of  themselves  rarely  cause  urethral  discharge, 
though  they  make  quite  incurable  one  which  was  originally  started  as  a  gonor- 
rhoeal  infection.  The  persistence  of  oxalates  or  phosphates  in  the  urine,  accom- 
panied by  a  mucoid  or  muco-purulent  discharge  neither  gonococcal  nor  tubercu- 
lous in  nature  and  unassociated  with  urethral  stricture,  polyp,  or  other  localized 
lesion,  would  justify  the  suspicion  that  the  discharge  is  dependent  on  the 
pathologic  condition  of  the  urine. 

Erethismic  Urethritis. — The  discharge  resulting  from  sexual  excesses  or 
prolonged  ungratified  sexual  excitement  is  mucoid  in  character.  It  may  be 
exceedingly  persistent  and  usually  indicates  a  urethra  especially  susceptible 
to  bacterial  infection. 

Treatment. — This  is  mainly  systemic.  Bromides  are  very  exceptionally  of 
service.  Hyoscine  hydrobromate,  grain  ^/oooj  twice  daily,  is  useful  when  the 
discharge  is  due  to  prolonged  ungratified  sexual  excitement.  For  this  condition 
the  psychrophore  is  also  serviceable  at  times.  As  a  rule,  local  treatment  is 
contraindicated.  Exercise,  hydrotherapy,  occupation,  and  diet  usually  suffice 
to  effect  a  cure. 

Eruptive  urethritis  is  often  overlooked.  It  is  due  to  an  active  hypersemia, 
with  perhaps  an  accompanying  eruption  on  the  mucous  membrane.  Doubtless 
the  irritating  condition  of  the  urine  is  a  contributing  factor.  The  appearance 
of  slight  urethral  discharge  coincident  with  the  development  of  the  skin  or 
mucous  membrane  lesions  of  the  fever,  the  elimination  of  other  sufficient  causes 
for  such  a  discharge,  and  the  disappearance  of  the  latter  with  the  betterment 
of  the  constitutional  condition,  would  indicate  the  diagnosis.  No  local  treatment 
is  needed. 

Herpetic  urethritis  is  characterized  by  a  sudden,  apparently  causeless, 
slight  discharge  commonly  accompanied  by  severe  neuralgic  or  burning  pain 


180  GENITO-URINARY  SURGERY 

greatly  exaggerated  during  micturition,  preceded,  followed  by,  or  alternating 
with  external  herpetic  lesions.  There  are  no  gonococci  and  there  is  no  involve- 
ment of  the  posterior  urethra. 

Mechanical  Urethritis. — A  persistent  urethral  discharge  in  a  healthy 
man,  whose  urine  is  normal  and  who  leads  a  fairly  healthful  life,  should  always 
suggest  the  likelihood  of  a  localized  urethral  lesion,  and  should  lead  to  an 
examination  for  stricture,  ulcer,  chronic  folliculitis,  or  urethral  polyp.  If  the 
discharge  has  been  preceded  by  a  sudden,  complete,  or  partial  stoppage  of  the 
urine  in  the  absence  of  a  history  of  previous  urethral  inflammation  the  lodge- 
ment of  a  calculus  should  be  suspected  (see  p.  164). 

Concomitant  Urethritis. — The  peri-  and  para-urethral  affections  causative 
of  urethra  discharge  include:  Folliculitis,  Cowperitis,  Prostatitis,  Vasitis, 
Seminal  vesiculitis  and  Cystitis. 

The  usual  cause  of  the  extra-urethral  affections  which  keep  up  the  dis- 
charge is  gonorrhoea.  The  history  ordinarily  shows  this  to  have  been  present. 
Before  its  continuance  can  be  eliminated,  it  will  be  necessary  to  make  fre- 
quently repeated,  painstaking  examinations  of  the  urethral  discharge,  the 
urine,  and  the  semen  for  gonococci,  microscopically  (by  the  Gram  method)  and 
sometimes  culturally.  When  there  is  no  history  of  gonorrhoea,  persistent  urethral 
discharge  secondary  to  infection  of  the  prostate,  seminal  vesicles,  vas,  or  bladder 
should  lead  to  careful  examination  for  tuberculosis. 

Even  though  a  urethral  discharge  be  found  associated  with  an  extraurethral 
affection,  its  dependence  upon  the  latter  cannot  be  assumed  till  all  other  causa- 
tive factors,  and  particularly  stricture  formation,  have  been  eliminated.  Con- 
comitant urethritides  are  examples  of  infective  urethritis,  but  are  given  separate 
consideration  because  of  the  influence  of  the  underlying  lesion  on  the  treatment 
of  the  condition. 

Infective  Urethritis. — Simple  purulent  inflammation  develops  after  un- 
clean sexual  intercourse  or  unclean  instrumentation,  particularly  in  those  who 
from  sexual  excess,  alcoholic  indulgence,  or  previous  attacks  of  urethritis  are 
especially  vulnerable.  .  The  exciting  cause  may  be  any  form  of  pyogenic 
organism,  the  Micrococcus  catarrhalis  more  often  than  any  other  than  the 
gonococcus.  This  bacterium,  similar  in  morphology  and  staining  reactions  to 
the  gonococcus,  though  less  uniformly  found  within  the  pus-cells,  can  be  differ- 
entiated from  the  latter  organism  with  absolute  certainty  only  by  biological 
methods.  The  urethritis  produced  is  of  a  mild  type,  and  usually  runs  a  brief 
course  without  complications,  though  it  may  be  quite  persistent. 

Symptoms. — These  vary  greatly.  For  the  mild  cases  the  following  is  de- 
"scriptive:  The  usual  cause  is  coitus  with  a  woman  suffering  from  leucorrhoea. 
It  is  characterized  by  a  varying  period  of  incubation,  usually  very  short,  at  most 
one  or  two  days,  by  a  reddened,  swollen  itching  meatus,  by  some  pain  on 
urination,  and  by  a  milky  secretion  from  the  urethra,  appearing  only  when  this 
canal  is  stripped  forward.  These  symptoms  are,  of  course,  identical  with  those 
of  the  earliest  stage  of  acute  gonorrhoea,  and,  except  by  microscopical  examina- 
tion of  the  discharge,  this  form  of  disease  cannot  be  distinguished  from  true 
gonorrhoea.  Its  course,  however,  is  different.  Unless  the  inflammation  is 
treated  by  irritants,  the  symptoms  do  not  increase  in  severity.     Neither  ardor 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   181 

urinae  por  chordee  develops.  The  discharge  continues  for  five  to  ten  days 
and  then  ceases  spontaneously.  There  are  no  sequelae  and  no  complications. 
The  condition  is  a  purely  catarrhal  one.  The  disease  subsides,  under  almost 
any  treatment  which  is  not  too  violent,  in  a  time  which  is  very  short  as  com- 
pared with  the  duration  of  ordinary  gonorrhoea.  The  attendant  is  often,  and 
not  unnaturally,  led  to  believe  that  such  subsidence  is  due  rather  to  his  treat- 
ment than  to  the  spontaneous  cessation  of  the  disorder. 

The  account  just  given  represents  the  usual  course  of  a  simple  infectious 
urethritis.  Exceptionally  the  inflammation  is  as  violent  and  prolonged  as  if 
from  gonococcus  infection.  In  strumous  and  cachectic  individuals  the  discharge 
may  remain  slight,  but  persists  for  weeks,  months,  or  years,  in  spite  of  treat- 
ment, and  commonly  brings  about  a  marked  condition  of  sexual  neurasthenia. 

Gonorrha-al  Urethritis. — This,  the  commonest  variety  of  urethritis,  and  the 
one  most  often  exhibiting  complications,  is  considered  in  a  separate  section 
(see  p.  183). 

Syphilitic  Urethritis. — A  urethral  discharge  may  be  due  to  primary,  secondary 
or  tertiary  syphilis.  Urethral  chancre,  usually  placed  within  half  an  inch  of 
the  meatus,  is  often  not  recognized  as  such  till  a  secondary  general  eruption  has 
clearly  indicated  the  nature  of  the  affection;  yet  in  the  absence  of  a  mixed 
infection  the  diagnosis  should  be  suggested  by  a  urethral  discharge  with  an 
incubation  period  longer  than  ten  days,  induration,  inflammatory  infiltration 
of  the  fraenum,  typical  bilateral  inguinal  adenitis,  and  the  detection  of  urethral 
ulcer  covered  by  a  grayish  pseudo-membrane. 

The  diagnosis  from  gonorrhoea  is  made  by  the  longer  incubation,'  usually 
three  weeks,  by  the  presence  of  induration  in  the  urethral  wall  near  the  meatus, 
as  determined  by  palpation,  and  of  an  ulcer  in  this  location,  revealed  by 
speculum  or  urethroscope,  by  the  general  absence  of  inflammatory  symptoms, 
particularly  of  ardor  urinae  and  painful  erections;  by  the  more  serous,  gono- 
coccus-free  discharge,  and  the  presence  of  Spirochcctcr  pallidcr  in  scrapings  from 
the  ulcer.  In  the  case  of  chancre  the  Wassermann  is  usually  positive  after  the 
second  week. 

The  urethral  chancroid  is  acutely  inflamed,  discharges  freely,  and  forms  a 
punched-out,  ragged,  nonindurated,  spreading  ulcer,  from'  the  exudate  of  which 
the  Ducrey  bacillus  may  be  recovered. 

A  persistent  mucoid  or  mucopurulent  discharge  also  characterizes  secondary 
and  tertiary  syphilitic  lesions,  which  are  found  in  the  urethra  as  areas  of 
congestion,  mucous  patches,  or  relapsing  gummatous  ulcerations.  Unless  there 
be  a  double  infection  gonococci  will  not  be  found.  Urethroscopic  examination 
shows  areas  of  non-indurated  exfoliation,  erosion,  or  ulceration,  usually  near  the 
meatus.  The  inflammatory  symptoms  are  mild  as  compared  to  gonorrhoeal, 
herpetic,  and  eczematous  eruptions;  and  in  the  pure  syphilitic  infection  there 
are  no  symptoms  referable  to  the  posterior  urethra. 

Treatment  .—This  is  that  appropriate  to  syphilis.  Local  treatment  is  rarely 
needed  except  for  the  cicatricial  contracture  following  gumma. 

Chancroidal  urethritis  begins  at  the  meatus  and  extends  backward.  The 
period  of  incubation  is  variable  (one  to  four  days  or  longer).  The  Ducrey  bacilli 
and  abundant  staphylococci  and  other  pyogenic  organisms  are  found  in  the 


182  GENITO-URINARY  SURGERY 

purulent,  often  blood-stained,  secretions,  but,  unless  double  infection  has  oc- 
cured,  no  gonococci;  not  infrequently  similar  lesions  are  noted  on  other  parts 
of  the  genital  organs.  Absence  of  induration  is  the  rule.  Inguinal  buboes  are 
common. 

The  subjective  symptoms  are  mild  compared  with  the  profuseness  of  the  dis- 
charge. In  the  absence  of  mixed  infection  there  are  no  deep-seated  compli- 
cations. Unlike  chancre,  which  may  be  entirely  intraurethral,  the  ulceration 
of  chancroid  either  develops  on  the  lips  of  the  meatus  or  shortly  appears  there, 
making  the  detection  of  its  presence  easy.  Urethral  chancroids  are  occasionally 
followed  by  fistulse,  and,  as  a  rule,  by  stricture,  unless  this  be  guarded  against 
in  the  course  of  healing. 

Treatment. — This  is  conducted  in  accordance  with  the  principles  laid  down 
in  the  treatment  of  chancroid  (see  p.  123).  Stricture  must  be  guarded  against 
by  the  use  of  a  meatus  bougie  during  the  process  of  healing. 

Tuberculous  Urethritis. — Till  recently  believed  to  be  a  most  uncommon 
lesion,  Pelouze  ^  has  shown  tuberculous  lesions  of  the  posterior  urethra  to  be 
of  fairly  frequent  occurrence.  A  chronic  urethral  discharge  was  present  in  all 
of  his  cases,  while  the  majority  of  them  complained  of  an  intense  burning  pain 
in  the  fossa  navicularis  during  urination;  a  smaller  number  of  pain  at  the  neck 
of  the  bladder.  The  lesions  found  consisted  of  lymphoid-like  masses,  from  one 
to  three  millimetres  across  on  the  lateral  walls  of  the  posterior  urethra.  In  a 
postmortem  specimen  these  were  found  to  be  surrounded  by  an  area  of  inflam- 
matory reaction;  through  the  posterior  urethroscope  they  appeared  paler  than 
the  urethral  mucosa  about  them,  distinctly  watery.  Tubercle  bacilli  were  found 
in  the  urine  of  the  majority  of  the  cases. 

Others  have  reported  the  occurrence  of  ulcerations  and  cheesy  infiltrations, 
chiefly  in  the  posterior  urethra,  but  also  in  the  anterior  portion  of  the  canal. 

Symptoms. — The  symptoms  of  urethral  tuberculosis  are  a  chronic  urethral 
discharge,  and,  when  the  disease  affects  the  posterior  urethra,  frequency  of 
urination,  tenesmus,  pain,  and  often  blood  at  the  end  of  urination.  Lesions 
of  the  anterior  urethra  usually  excite  no  symptoms  other  than  a  slight  muco- 
purulent discharge.  Injection  of  silver  nitrate  ordinarily  occasions  a  violent 
reaction  and  is  followed  by  severe  pain  which  may  persist  for  weeks  or  months. 

Diagnosis. — The  diagnosis  of  urethral  tuberculosis  is  founded  on  the  discov- 
ery of  the  tubercle  bacillus,  the  association  of  the  lesions  with  evidence  of  tuber- 
culous infection  in  other  parts  of  the  body,  particularly  in  the  genital  tract  and  in 
the  lungs,  and  urethroscopic  examination.  An  apparently  causeless  purulent 
urethral  discharge  should  always  suggest  a  careful  search  for  tubercle  bacilli. 

Treatment  .—The  treatment  is  dependent  upon  the  extent  and  multiplicity 
of  lesions  other  than  those  found  in  the  urethra.  When  the  urethral  infiltration 
is  simply  a  part  of  a  general  infection,  irrigation,  and  instillation  of  bichloride 
solution  1  to  6000  once  daily,  and  the  use  of  iodoform  bougies  ten  per  cent, 
in  cacao  butter  or  gelatin,  or  of  iodoform  insufflated  through  the  tube  of  an 
endoscope,  represent  as  active  local  treatment  as  is  serviceable.     A  single  or 

^American  Journal  of  Urology,  1917.  ■  •    ■ 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE    183 

limited  infiltration  should,  in  the  absence  of  lesions  elsewhere,  be  thoroughly 
curetted  or  removed  by  an  external  urethrotomy,  the  urethra  being  resected 
and  subsequently  sutured  should  complete  removal  require  this.  Tuberculin 
therapy  is  a  useful  adjuvant. 

Typhoidal  Urethritis. — The  urethral  inflammation  sometimes  accompany- 
ing typhoid  fever  is  probably  dependent  upon  congestion  induced  by  the  con- 
centrated febrile  urine,  which  in  turn  favors  infection  by  the  bacillus  coli  com- 
munis and  other  pyogenic  bacteria.  The  discharge  is  mucopurulent  in  char- 
acter, rarely  profuse,  contains  abundant  pyogenic  bacilli,  pus-cells,  mucus,  and 
epithelium  without  gonococci.    There  is  always  accompanying  cystitis. 

Prognosis. — During  or  immediately  following  the  appearance  of  typhoidal 
urethritis,  but  generally  later  in  the  course  of  the  fever,  there  may  develop 
epididymoorchitis.  The  latter,  however,  is  generally  a  pure  typhoid  infection 
occurring  through  the  blood  (see  p.  324).  The  urethral  discharge  promptly 
disappears  as  convalescence  progresses. 

Treatment. — ^TJie  urine  should  be  rendered  bland.  Urinary  antiseptics  are 
indicated. 

Influenzal  urethritis  is  also  due  to  pyogenic  infection,  and  its  relation  to 
influenza  is  coincident. 

Pneumococcic  and  diphtheric  urethritis  are  more  truly  specific,  since  in 
these  forms  the  specific  bacteria  may  be  abundant  and  there  is  (in  the  diph- 
theritic) membrane  formation. 

Symptoms. — These  are  severe,  the  discharge  profuse,  purulent,  and  blood- 
stained. There  may  be  shreds  of  membrane  exfoliated.  Constitutional  symp- 
toms, fever,  etc.,  coexist.  Yet  rarely  does  the  process  extend  further  than  the 
anterior  urethra.    The  pneumococcic  is  far  less  severe  than  the  diphtheritic. 

Diagnosis  depends  on  the  bacteriologic  examination,  since  false  membranes 
may  form  in  other  varieties  of  severe  urethritis. 

Prognosis  is  favorable,  the  disease  being  usually  short  in  duration. 

Treatment  should  be  constitutional  and  local.  Antitoxin  should  be  employed 
against  diphtheria.    Locally,  mild  antiseptic  irrigations  are  indicated. 

GONORRHOEA 

Gonorrhoea  is  a  contagious  specific  inflammation  of  the  mucous  membranes 
of  the  genito-urinary  tract.  It  also  affects  the  conjunctiva  and  the  mucous 
membranes  of  the  rectum  and  mouth. 

Etiology. — Gonorrhoea  depends  for  its  development,  upon  the  presence  of 
a  specific  microbe  termed  the  gonococcus.  It  usually  runs  a  somewhat  typical 
course — one  longer  and  attended  with  more  complications  than  nongonococcal 
urethritis. 

The  gonococcus  when  cultivated  on  a  suitable  medium  shows  a  very  small, 
scarcely  perceptible  grayish  surface,  appearing  shiny,  moist,  and  slightly  yellow- 
ish by  reflected  light.  The  development  of  this  culture  is  slow,  and  the  growth 
never  extends  widely,  reaching  its  uttermost  dimensions  in  two  or  three  days. 


184  GENITO-URINARY  SURGERY 

after  which  time  the  germs  lose  their  virulence,  and  shortly  can  no  longer  be 

transplanted  with  successful  results.    The  growth  is  always  on  the  surface.    It 
is  inhibited  by  extremely  weak  antiseptic  solutions. 

Gonococci  grow  best  at  a  temperature  of  36°  G.  The  best  medium  for  rou- 
tine use  is  prepared  by  adding  five  drops  of  rabbit-blood  to  eight  or  ten  cubic 
centimetres  of  ordinary  nutrient  agar,  1  per  cent,  acid  to  phenolphthalein.  The 
blood  should  be  allowed  to  drop  from  the  opened  vein  in  the  ear  of  a  rabbit 
directly  into  the  agar,  which  has  been  melted  and  cooled  to  a  temperature 
between  40°  and  55°  G.  The  blood  is  distributed  through  the  agar  by  rolling 
the  tube  between  the  palms,  and  the  tube  is  slanted.  This  medium  has  been 
found  to  combine  the  advantages  of  reliability  and  ease  of  preparation.  Even 
on  it  a  growth  is  not  invariably  obtained,  especially  when  the  pus  has  been 
taken  from  a  chronic  case,  so  that  a  negative  result  cannot  be  taken  to  prove 
the  absence  of  the  organisms. 

The  gonococcus  is  distinguished  by  its  shape,  grouping,  position,  color 
reaction,  and  growth  on  artificial  media. 

In  shape  the  gonococci  resemble  the  two  seeds  of  a  coffee-bean, — that  is, 
they  are  diplococci,  flat  or  slightly  concave  on  one  side,  and  rounded  on  the 
other,  with  their  flat  (Plates  II  and  III)  surfaces  apposed.  In  the  process  of  mul- 
tiplication each  half  of  the  diplococcus  divides  at  right  angles  to  the  fissure  be- 
tween the  two.  Hence  the  gonococci  are  always  grouped  in  irregularly  shaped 
colonies;  chains  are  never  found.  They  quickly  take  the  stain  of  ordinary  basic 
staining  reagents,  such  as  fuchsin,  methyl  or  gentian  violet,  or  methylene  blue, 
and  are  readily  decolorized  by  the  Gram  method,  this  fact  serving  to  distinguish 
them  from  other  urethral  cocci,  except  the  Micrococcus  catarrhalis.  (For  the 
methods  of  staining  pus  see  Ghapter  II,  page  19.) 

If  Gram-negative  characteristic  biscuit-shaped  diplococci,  arranged  in  pairs, 
jours,  and  other  multiples  of  two,  showing  a  tendency  to  rectangular  disposition, 
and  located  within  the  cellular  elements  are  discovered  in  urethral  pus  the 
diagnosis  of  gonorrhoeal  urethritis  is  sufficiently  positive  for  all  clinical  pur- 
poses. If,  however,  negative  results  are  obtained — i.e.,  if  gonococci  are  not 
found — we  cannot  be  absolutely  sure  the  patient  has  not  gonorrhoea. 

In  medico-legal  cases  or  in  cases  involving  a  question  of  chastity  or  of  family 
relations,  repeated  examinations  may  be  required  and  the  concurrent  circum- 
stances should  be  given  full  weight  in  reaching  a  conclusion.  The  obtaining 
of  cultures  of  the  gonococcus  is  conclusive  evidence,  but  inability  to  obtain  a 
growth  cannot  be  given  similar  consideration.  The  complement  fixation  test  is 
of  greater  utility. 

Failure  to  find  the  organisms  may  be  incident  to  faulty  technique  or  to 
imperfectly  prepared  reagents.  The  organisms  may  be  so  deeply  situated  in  the 
submucous  tissue  or  the  paraurethral  glands  that  they  are  found  in  the  dis- 
charge only  when  it  has  been  aggravated.  Hence  it  is  helpful  to  make  the 
examination  the  morning  after  a  night  of  dissipation  or  a  dinner  of  highh'- 
irritating  food,  or  a  horseback  or  bicycle  ride,  or  to  set  up  a  more  or  less  acute 
superficial  inflammation  by  instrumentation  or  irritating  injection,  or  to  examine 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   185 

the  discharge   expressed  by  massage   of   the  prostate,   seminal   vesicles,   and 
Cowper's  glands. 

The  important  characteristics  of  gonococci  may  be  summarized  as  follows: 
they  are  diplococci;  they  appear  in  heaps,  which  nearly  always  occupy  the 
protoplasm  of  cells;  they  are  very  numerous  in  acute  cases;  they  are  readily 
colored  by  aniline  dyes  and  decolorized  by  Gram's  method  of  staining;  they  are 
nonpathogenic  to  lower  animals. 

Character  of  the  Discharge. — From  a  microscopic  standpoint,  gonorrhoea! 
discharges  consist  of  an  albuminous  fluid  in  which  are  distributed  mucus,  pus- 
cells,  epithelial  cells,  and  bacteria  in  greatly  varying  proportions.  In  the  early 
hours  of  the  discharge  the  number  of  epithelial  cells  is  comparatively  large, 
and  that  of  the  pus-cells  comparatively  small;  gonococci  are  not  plentiful,  and 
in  the  main  are  located  without  the  cells.  The  epithelial  cells  are  small  in 
size,  and  contain  large,  deeply-staining  nuclei. 

During  the  height  of  the  attack  the  pus-cells  are  the  most  prominent  con- 
stituent. Gonococci  are  present  in  enormous  numbers,  the  great  majority  of 
them  lying  within  the  bodies  of  pus-cells.  The  number  of  epithelial  cells  is 
small,  both  relatively  and  absolutely.    A  small  amount  of  mucus  is  present. 

During  the  declining  stages  of  a  gonorrhoea  a  constantly  increasing  amount 
of  mucus  is  seen,  and  the  number  of  pus-cells  becomes  correspondingly  dimin- 
ished. However,  it  is  impossible  to  describe  a  single  condition  as  typical  of 
this  stage,  for  the  picture  is  a  changing  one.  Thus,  in  the  same  patient  the 
lapse  of  a  few  days  during  which  there  have  been  indiscretions  in  diet,  etc., 
may  cause  a  discharge  which  had  been  of  a  distinctly  mucoid  character  to 
assume  the  characteristics  of  the  exudate  of  the  acute  form  of  the  disease.  In 
the  main,  however,  there  is  a  decrease  in  the  pus-cells  and  gonococci,  and  an 
increase  of  mucus,  epithelial  cells,  and  contaminating  bacteria.  The  epithelial 
cells  are  generally  larger  than  those  seen  in  the  early  stages  of  the  disease,  and 
have  much  smaller  nuclei. 

Gonorrhoeal  shreds  are  classed  clinically  as  mucoid,  mucopurulent,  or  puru- 
lent, the  different  groups  being  differentiated  by  their  relative  buoyancy,  the 
mucoid  shreds  floating  near  the  surface  of  the  freshly  voided  urine,  whereas 
those  containing  a  large  amount  of  pus  sink  rapidly  to  the  bottom.  From  a 
microscopic  standpoint,  shreds  consist  of  an  albuminous  matrix  in  which  are 
embedded  pus-cells,  epithelial  cells,  and  small  numbers  of  bacteria.  It  is  very 
unusual  to  see  a  shred  which  is  entirely  free  from  pus-cells,  and  consisting  only 
of  mucus,  or  of  mucoid  material  and  epithelial  cells. 

Shreds  are  most  easily  transferred  to  the  slide  or  cover-glass  by  means  of  a 
pipette,  or  by  floating  them  on  the  submerged  glass,  the  urine  being  removed 
from  about  the  specimen  with  filter-paper. 

Source  of  Discharge. — Pus  formed  in  the  anterior  urethra  tends  to  flow 
forward  and  appear  at  the  meatus;  pus  from  the  posterior  part  of  the  canal 
makes  its  way  backward  into  the  bladder.  (For  reasons  for  this  distribution 
and  methods  of  determining  the  origin  of  pus  see  page  14.) 

Pathogenesis  and  Pathology. — Gonococci,  deposited  on  the  mucosa  of  the 
urethra,  lie  upon  its  surface  for  from  six  to  twelve  hours.  At  the  end  of  this 
time  they  pass  through  the  mucosa,  chiefly  through  the  intercellular  substance, 


186  GENITO-URINARY  SURGERY 

penetrating  to  the  papillary  layer,  and  in  the  neighborhood  of  the  urethral 
glands,  invading  the  submucosal  connective  tissue.  The  epithelia  of  the  fol- 
licles and  of  the  ducts  of  the  glands  become  infected  along  with  the  surface 
mucosa,  but  the  secreting  epithelium  of  the  glands  escapes. 

Sections  of  the  mucosa  show  it  to  be  the  seat  of  cloudy  swelling  and  round- 
cell  infiltration,  with  desquamation  of  the  superficial  cells.  The  pathological 
changes  are  most  marked  in  the  neighborhood  of  the  glands  and  follicles,  the 
intervening  smooth  mucosa  being  comparatively  normal.  In  the  later  stages  of 
urethritis  the  mucosa  becomes  changed  from  a  simple  columnar  epithelium  to 
a  stratified  structure  with  large  squamous  cells  on  its  surface.  At  this  time 
there  is  also  a  development  of  fibrous  tissue,  which  by  the  contraction  char- 
acteristic of  this  substance  lessens  the  calibre  of  the  urethra  and  obliterates  the 
glands  and  their  ducts. 

The  role  of  the  gonococci  in  the  later  stages  of  the  disease  is  not  clear,  but 
it  seems  probable  that  they  lie  in  the  deeper  portions  of  the  mucosa  during  the 
periods  of  remission  of  symptoms,  being  carried  to  the  surface  in  the  bodies  of 
the  leucocytes,  with  consequent  Assuring  of  this  membrane,  at  times  of  exacer- 
bations of  the  disease. 

TYPICAL  ACUTE  GONORRHOEA  OF  THE  MALE  URETHRA 

This  form  of  urethral  inflammation  is  due  to  infection  of  the  urethra  with  the 
gonococcus.  Such  infection  is  nearly  always  due  to  sexual  intercourse,  the 
virulent  pus  from  the  female  entering  the  male  urethra  to  a  greater  or  less  depth. 
This  method  of  acquiring  the  disease  is  termed  immediate  contagion. 

The  disease  also  may  be  conveyed  by  mediate  contagion, — that  is,  through  the 
medium  of  clothing  or  other  articles  containing  the  specific  microorganisms. 
Since  to  excite  inflammation  the  microorganisms  must  gain  access  to  the  urethra, 
it  can  readily  be  seen  that  mediate  contagion,  excepting  by  the  agency  of  bodies 
introduced  within  the  urethra,  must  be  exceedingly  rare. 

Gonorrhoea  of  the  male  urethra,  in  accordance  with  its  clinical  course, 
may  be  mild,  subacute  or  catarrhal,  severe,  neurotic  or  neuralgic,  recurrent 
or  relapsing,  or  intractable. 

Mild  gonorrhoea  is  characterized  by  long  incubation,  moderate  symptoms, 
absence  of  com.plications,  and  at  times  rapid  cure,  though  the  disease  may 
be  indefinitely  prolonged.  Treatment,  both  local  and  hygienic,  should  be 
carried  out  faithfully  as  would  be  indicated  for  a  more  severe  attack. 

Subacute  or  Catarrhal  Gonorrhoea. — This  occurs  most  frequently  in  persons 
who  have  suffered  from  a  previous  attack  of  gonorrhoea,  and  exemplifies  the 
tendency  manifested  by  the  mucous  structures  to  become  readily  excited  to 
inflammation  from  slight  causes  after  having  been  once  affected.  This  is  par- 
ticularly noticeable  in  the  urethra,  because  this  canal  affords  periodical  passage 
for  the  urine,  which,  from  changes  in  its  constitution,  may  become  an  irritant. 
During  erection  it  is  exposed  to  intense  congestion.  On  account  of  its  free 
blood-supply  and  of  the  absence  of  firm  extravascular  support,  the  blood- 
vessels remain  in  an  atonic  condition  and  become  greatly  congested  on  slight 
provocation  long  after  apparent  complete  recovery  from  an  attack  of  urethritis. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   187 

The  close  apposition  of  the  mucous  surfaces  except  during  micturition  also 
favors  the  continuance  of  granular  or  congested  areas  or  other  traces  of  in- 
flammation; hence  but  few  who  have  had  one  attack  of  gonorrhoea  escape 
subsequent  manifestations,  infection  too  feeble  to  overcome  the  resistance  of 
a  healthy  urethra  finding  under  such  circumstances  favorable  soil. 

Symptoms.— In  this  form  of  gonorrhoea  the  incubation  period  is  exceedingly 
variable  (one  to  ten  days),  and  there  is  often  no  inflammatory  symptom 
beyond  a  profuse  mucopurulent  urethral  discharge.  There  may  be  a  slight 
feeling  of  warmth  during  urination  and  some  increased  sexual  excitability, 
but  ardor  urinae  and  painful  erections  are  usually  absent.  A  pure  pus  dis- 
charge is  very  rare,  the  latter  being  mainly  mucous  or  serous.  Gonococci  and 
pus-cells  are  not  abundant,  but  are  found,  together  with  epithehal  cells, 
principally  of  the  flat  and  transitional  variety.  The  inflammation  seems  to 
be  purely  superficial  in  its  nature,  and  the  disease  is  rarely  attended  by  local 
complications.  This  form  of  discharge  should  be  differentiated  from  that 
due  to  urethral  syphilis  (see  p.  181). 

Under  treatment  the  discharge  rapidly  diminishes  in  quantity  until  only 
a  drop  of  mucus  is  found  in  the  morning;  but  this  symptom  is  liable  to  persist 
for  a  long  period,  and  is  exceedingly  difficult  to  suppress. 

Severe  or  virulent  gonorrhoea  occurs  in  those  whose  urethras  are  predisposed 
to  inflammation  by  intense  congestion,  such  as  results  from  alcoholic  and 
venereal  excesses.  It  is  also  observed  in  healthy  young  men,  who  have  never 
had  a  similar  infection  and  who  have  practised  ill-advised,  irritating  injections 
in  the  hope  of  preventing  gonococcal  infection. 

The  period  of  incubation  is  short,  the  subjective  symptoms  are  severe. 
The  discharge  is  profuse  and  bloody,  marked  posterior  urethral  involvement 
occurs  early.  Blood-stained  pollutions,  ardor  urinae,  often  retention  of  urine, 
painful  erections  and  chordee,  harass  the  patient,  who  is  still  further  weakened 
by  fever  due  to  septic  absorption.  Complications  are  common  and  trouble- 
some. The  course  of  the  disease  is  usually  prolonged.  Treatment  should 
be  active,  and  stringent  to  the  minutest  detail.  Rest  in  bed,  diluents,  a  milk 
and  butter-milk  diet,  hot  sitz-baths,  and  regular  evacuations  from  the  bowels 
are  means  best  calculated  to  prevent  complications  and  to  hasten  cure. 

Neurotic  {or  neuralgic)  gonorrha:a  is  characterized  by  hyperacute  subjec- 
tive symptoms,  out  of  proportion  to  the  amount  of  discharge.  The  irritable 
cases  show  excessive  local  pain.  Injections  and  irrigations  are  intolerable, 
and  often  cause  bleeding.  Erections  and  chordee  are  frequent.  Local  tender- 
ness is  severe.  For  these  cases  full  doses  of  bromide  are  indicated.  Hyoscine 
hydrobromate,  grain  ^/loo;  o^  hyoscyamine  sulphate,  grain  ^/-^^o,  at  bedtime 
will  relieve  the  chordee.  Hygienic,  dietetic,  and  internal  medical  treatment 
must  be  stringent.  Drugs  stimulating  to  the  mucous  membrane,  such  as 
copaiba,  and  cubebs,  must  be  omitted.  Local  injections  and  irrigations  are  ^ 
contra-indicated  until  the  subsiding  stage. 

Neurotic  or  neuralgic  gonorrhoea  is  often  associated  with  neurasthenia  or 
even  melancholia;  there  is  a  distrust  of  treatment  and  impatience  at  the  slow- 
ness of  results,  with  a  tendency  to  try  secretly  every  suggestion,  independent 
of  its  source.     The  discharge  and  local  symptoms  may  be  mild,  but  the  dis- 


188  GENITO-URINARY  SURGERY 

ease  tends  to  become  intractable  as  a  result  of  diversified  treatment.  Due 
consideration  to  the  neurasthenic  element  should  be  given  in  the  management 
of  these  cases. 

Relapsing  and  recurrent  gonorrhoea,  if  not  due  to  reinfection,  is  usually 
incident  to  an  almost  symptomless  chronic  posterior  urethritis.  Exceptionally, 
a  gonorrhoeal  cowperitis  or  folliculitis  is  the  cause.  The  treatment  consists 
in  finding  and  ablating  the  focus  of  the  recurring  urethral  infection. 

Intractable  gonorrhoea  is  always  due  to  a  persistent  lesion,  usually  a  follic- 
ulitis associated  after  months  and  years  with  stricture  formation.  As  a  rule, 
it  is  observed  in  persons  impatient  of  restraint,  who  before  complete  cure 
of  an  acute  case  revert  to  the  excesses  which  were  responsible  for  the  original 
attack.  The  treatment  of  these  cases  is  dependent  on  finding  and  eliminating 
the  local  lesion.    A  very  small  percentage  of  these  cases  are  tuberculous. 

Incubation. — There  is  always  an  interval  of  time  between  exposure  to 
contagion  and  the  development  of  noticeable  urethral  symptoms.  During 
this  time  the  germs  are  multiplying,  and  a  focus  of  inflammation  is  becoming 
established  sufficiently  extensive  and  intense  to  excite  attention.  This  time 
varies  between  a  few  hours  and  two  or  three  weeks,  since  it  depends  upon 
the  original  strength  of  the  microbic  invasion,  the  seat  of  entrance,  and  the 
vital  resistance  of  the  mucous  membrane.  An  extremely  short  incubation 
period  or  one  which  is  unusually  long  should  always  lead  the  surgeon  to  doubt 
the  gonorrhoeal  nature  of  the  urethritis  till  this  is  determined  by  microscopic 
examination.  Three  to  five  days  represent  the  ordinary  incubation  period, — 
that  is,  the  time  elapsing  between  exposure  to  the  disease  and  the  development 
of  the  first  symptom. 

Prodromal  Symptoms. — Often  the  first  symptom  of  a  developing  urethritis 
is  a  constantly  recurring  tendency  to  fix  the  attention  on  the  penis.  Even 
though  the  parts  seem  perfectly  normal,  there  is  a  strong  desire  to  subject 
them  to  frequent  inspection. 

A  sense  of  heat  and  itching  in  the  glans,  slight  fugitive  tickling  sensa- 
tions at  the  meatus,  together  with  a  feeling  of  weight  and  tension  in  the  penis 
and  a  tendency  to  develop  erection  on  the  slightest  excitement,  are  most  fre- 
quently noticed. 

Inflammatory  Symptoms. — In  twenty- four  hours  symptoms  of  inflam- 
mation become  more  pronounced;  there  are  now  developed  (1)  swelling  of 
the  meatus  and  (2)  discharge,  becoming  more  and  more  marked  from  day 
to  day,  and  shortly  supplemented  by  (3)  ardor  urinae  and  (4)  sometimes 
painful  erections,  later  by    (5)    frequent  urination  and  vesical  tenesmus. 

Inflammatory  Swelling. — 1.  The  lips  of  the  meatus  are  swollen  and 
oedematous,  often  everted.  The  swelling  may  be  so  great  that  the  urine  can 
be  passed  only  in  a  slow  stream.    Usually  the  stream  is  forked  and  irregular. 

In  severe  cases  the  glans  becomes  gorged  with  blood,  and  the  foreskin  may 
be  swollen,  reddened,  and  oedematous.  Enlarged  lymphatic  vessels  may  be 
felt  passing  as  hard  cords  from  the  frsenum  to  the  back  of  the  penis. 

The  urethra  swells  and  becomes  tender  on  pressure.  It  is  at  times  nodular, 
owing  to  involvement  of  the  glands  and  follicles. 

2.  The  discharge,  at  first  scanty  and  of  milk-and-water  color,   turns  to 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE    189 

a  greenish  yellow,  and  may  be  mixed  with  blood  from  the  congested  mucous 
membrane.  It  varies  in  quantity  in  accordance  with  the  extent  and  violence 
of  the  inflammation,  increasing  till  the  disease  has  reached  its  acme.  Finally 
the  pus  entirely  disappears,  usually  leaving  for  days  or  weeks  an  oversecretion 
of  mucus,  which  appears  in  the  urine  as  long,  irregular,  translucent  shreds. 

3.  Ardor  urinae,  or  pain  during  urination,  becomes  well  marked  within 
the  first  few  days.  The  pain  is  commonly  referred  to  the  meatus  or  to  the 
navicular  fossa.  It  is  often  felt,  however,  along  the  entire  anterior  urethra, 
and  may  be  reflected  to  the  anal  region.  This  pain  is  caused  mainly  by  the 
action  of  acid  urine  on  the  inflamed  mucous  membrane,  as  is  shown  by  the 
soothing  effect  of  alkaline  diuretics. 

Not  only  is  there  burning  on  urination,  but  from  slight  mechanical  dis- 
turbance, or  even  without  obvious  cause,  sharp,  cutting,  stabbing  pains  are 
felt  along  the  course  of  the  pendulous  urethra  at  various  times.  These  may 
be  so  constant  and  annoying  as  to  prevent  all  but  absolutely  necessary  move- 
m.ents. 

4.  Painful  Erection. — Even  in  the  period  of  incubation  there  is  usually 
increased  sexual  excitement,  manifested  by  frequent  and  long-continued  erec-- 
tions  and  even  by  increased  pleasure  in  copulation.  As  the  inflammation  be- 
comes more  intense  and  widespread  the  erections  become  more  persistent  and 
are  accompanied  by  pain  which  is  often  so  severe  that  it  constitutes  one  of 
the  most  harassing  symptoms  of  the  disorder.  This  pain  is  due  to  the  fact 
that  the  congested  infiltrated  mucous  membrane  and  submucous  connective 
tissue  is  not  able  to  stretch  as  it  normally  does  when  the  cavernous  bodies 
become  engorged  with  blood.  The  tension  upon  the  now  nonelastic  urethra 
is  still  further  increased  by  a  clonic  contraction  of  the  ischiocavernous  and 
bulbocavernous  muscles,  which  swing  the  penis  upward  against  the  abdomi- 
nal waUs. 

Painful  erection  is  present  to  a  greater  or  less  extent  in  all  cases.  It  occurs 
most  frequently  during  the  sleeping  hours,  though  it  may  give  trouble  at 
any  time,  day  or  night.  The  pain  is  felt  mainly  along  the  under  surface 
or  on  the  sides  of  the  penis,  and  by  its  persistence  either  awakens  the  patient 
or  keeps  him  awake. 

When  inflammation  is  unusually  severe,  chordee  develops — that  is,  during 
erection  the  penis  is  curved  or  bent,  usually  downward,  though  lateral  or 
upward  curving  is  sometimes  observed.  In  these  cases  the  pain  is  generally 
severer  than  when  there  is  no  such  deformity.  The  bending  of  the  organ 
is  due  to  the  inflammatory  infiltration  of  one  or  more  of  the  erectile  bodies, 
complete  engorgement  being  thereby  prevented.  The  bending  is  toward  the 
body  or  bodies  most  affected  by  the  inflammation. 

Complete  or  partial  rupture  of  the  urethra  is  the  usual  result  of  violent 
attempts  to  straighten  the  penis,  breaking  a  chordee,  as  it  is  called,  sometimes 
indulged  in  by  patients  driven  to  exasperation  by  the  tormenting  pain  of  the 
condition. 

5.  Urgent  and  Frequent  Urination. — These  symptoms  are  signs  of  the 
involvement  of  the  posterior  urethra. 


190  GENITO-URINARY  SURGERY 

ACUTE  POSTERIOR  URETHRITIS 

Infection  of  the  portion  of  the  urethra  proximal  to  the  compressor  urethrae 
muscle  commonly  takes  place  about  the  end  of  the  first  week;  it  may,  however, 
occur  during  the  first  few  days  of  the  disease,  especially  when  injections  have 
been  used  too  energetically  or  instruments  have  been  passed,  or  its  onset  may 
be  postponed  till  a  much  later  date;  exceptionally  this  portion  of  the  urethra 
may  remain  free  from  the  disease. 

The  presence  of  posterior  urethritis  may  be  recognizable  only  by  examina- 
tion of  the  urine,  subjective  symptoms  being  entirely  wanting,  or  these  symp- 
toms may  be  so  marked  that  the  patient  is  in  continual  distress.  Frequent, 
urgent  urination  is  generally  the  first  subjective  symptom  of  the  condition, 
and  is  due  to  the  fact  that  in  its  acutely  inflamed  state  the  mucous  mem- 
brane of  the  posterior  urethra  greatly  magnifies  the  impulse  caused  by  urinary 
contact,  the  demand  for  evacuation  being  so  imperative  that  it  may  not  be 
denied.  An  additional  reason  for  the  symptom  lies  in  the  customary  involve- 
ment of  the  vesical  mucosa  in  the  immediate  vicinity  of  the  urethral  orifice 
in  the  disease  process. 

The  milder  cases  are  characterized  by  frequency.  In  the  more  marked 
cases  the  frequently  recurring  desire  becomes  imperative;  the  forceful  strain- 
ing effort  may  void  but  a  few  drops,  the  passage  of  which  gives  little  relief. 

Terminal  Hccmaturia. — In  addition  to  the  tenesmus,  there  is  frequently 
haematuria — a  few  drops  of  pure  blood  running  from  the  urethra  at  the  end 
of  urination.  This  is  squeezed  from  the  swollen,  congested,  often  eroded  mucous 
membrane  of  the  prostatic  urethra.  Hemorrhage  may  be  very  free.  In  this 
case  the  blood  flows  back  into  the  bladder  and  the  patient  passes  it  mixed 
with  his  urine  at  the  next  micturition. 

Albuminuria. — During  the  period  when  vesical  tenesmus  is  most  marked 
there,  is  always  a  quantity  of  albumin  in  the  urine  greater  than  can  be  ac- 
counted for  by  the  pus  present.  This  is  probably  due  to  damming  back 
of  the  urine  in  the  ureters,  dependent  upon  closure  of  the  orifices  of  these 
canals  by  contraction  of  the  detrusor  muscles  of  the  bladder,  this  having 
been  shown  to  take  place  when  tenesmus  is  severe. 

Periiieal  Pain. — This  when  due  to  tenesmus,  i.e.,  muscular  spasm,  may  be 
almost  unbearable  in  its  intensity.  Aside  from  the  suffering  by  muscular  spasm 
there  are  usually  tickling,  burning,  or  shooting  pains  in  the  deep  urethra  and 
about  the  rectum.     These  are  aggravated  by  micturition  or  defecation. 

Erections  are  frequent,  but  are  painless  unless  there  is  at  the  same  time 
acute  anterior  urethritis. 

Nocturnal  emissions  occur  repeatedly,  and  are  almost  symptomatic  of  in- 
flammation of  the  posterior  urethra.  They  are  due  to  hyperaesthesia  of  the 
caput  gallinaginis,  and  are  often  painful,  the  distress  being  referred  to  the 
deep  urethra. 

Constitutional  Involvement. — Even  in  mild  cases  there  are,  as  a  rule,  transi- 
tory fever  and  slight  malaise.  Incident  to  acute  posterior  involvement,  even 
when  the  local  symptoms  are  not  especially  well  marked,  there  are  often 
pronounced  fever,  headache,  pains  through  the  body,  particularly  in  the  back. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE    191 

loss  of  appetite,  and  the  general  misery  so  identified  with  "grippe"  that  the 
patient  himself  usually  makes  this  diagnosis  of  his  condition. 

Complications. — In  the  increasing  stage,  balanitis,  balanoposthitis,  phi- 
mosis, and  paraphimosis  are  the  common  complications;  in  the  stationary  stage, 
folliculitis  and  periurethritis,  lymphangitis,  lymphadenitis,  cavernitis,  and 
cowperitis.  The  complications  of  posterior  urethritis  are  prostatitis,  seminal 
vesiculitis,  epididymitis,  and  infection  of  the  upper  urinary  tract  (rare).  The 
metastatic  lesions  of  gonorrhoea,  arthritis,  endocarditis,  etc.,  are  generally  the 
sequelae  of  posterior  urethritis  or  one  of  its  complications. 

Prognosis  of  Acute  Gonorrhoeal  Urethritis. — This  specific  inflamma- 
tion runs  its  course  in  from  five  to  eight  weeks.  If  carefully  treated,  the 
discharge  disappears,  the  urine  remaining  absolutely  clear  of  shreds,  and  the 
disease  is  cured.  At  times,  even  though  treatment  has  been  judicious  and 
has  been  rigidly  carried  out,  the  acute  inflammation  runs  into  the  chronic 
form,  manifested  by  a  gleety  discharge  lasting  longer  than  eight  weeks; 
or,  in  the  case  of  the  posterior  urethra,  by  constantly  recurring  subacute 
attacks  and  sexual  neuroses  of  all  types.  This  is  especially  liable  to  occur 
in  the  strumous  and  cachectic,  in  those  of  gouty  or  rheumatic  tendency,  and 
in  patients  who  are  careless  in  respect  to  treatment  and  impatient  under 
restraint.  The  prognosis  as  to  the  time  when  cure  can  be  expected  must 
always  be  guarded. 

TREATMENT  OF  ACUTE  GONORRHCEA  IN  THE  MALE 

Prophylaxis. — The  use  of  a  cover  sufficiently  strong  to  remain  unbroken 
during  coitus,  with  careful  ablution  and  urination  on  the  completion  of  the 
act,  is  the  best  means  of  preventing  contagion. 

If  this  be  not  done  one  of  the  following  methods  should  be  employed:  Im- 
mediately after  intercourse  thorough  washing  of  the  penis  and  surrounding  parts 
with  soap  and  water,  and  urination  with  as  full  a  stream  as  possible,  the  flow 
being  checked  several  times  during  the  act  by  pinching  the  meatus.  As  soon 
thereafter  as  practicable  medication  of  the  urethral  mucosa  by: 

The  introduction  of  a  small  quantity  of  33%  calomel  in  lanoHn  (dispensed 
in  a  collapsible  tube  for  convenience  in  carrying,  or 

Injection  of  a  few  drops  of  protargol  (0.5%)  or  argyrol  (20%),  retaining 
them  for  at  least  five  minutes,  or 

Irrigation  of  the  anterior  portion  of  the  anterior  urethra  with  silver  nitrate 
(1:5000)  or  potassium  permanganate  (1:4000). 

Aboetive  Treatment. — When  patients  apply  for  treatment  within  forty- 
eight  hours  of  the  beginning  of  symptoms  it  is  frequently  possible  to  materially 
shorten  the  course  of  the  disease.  In  applying  treatment  for  this  purpose  it  is 
of  the  utmost  importance  to  avoid  any  measures  which,  in  the  event  of  their 
failure  to  cure  the  disease,  will  leave  the  urethra  in  a  worse  condition  than  had 
no  treatment  been  administered.     Ballenger's  method  is  as  follows: 

The  penis  is  cleansed  and  the  meatus  anesthetized  by  laying  across  it 
cotton  wet  with  10  per  cent,  cocaine.  Thereafter  25  minims  of  a  freshly-pre- 
pared 5  per  cent,  solution  of  argyrol  are  injected  and  retained  by  pressing  the 
lips  of  the  meatus  together  and  sealing  them  so  with  flexible  collodion.     To 


192  GENITO-URIXARY  SURGERY 

facilitate  removal  of  the  occluding  film  a  tiny  piece  of  gauze  may  be  included 
in  the  margin  of  the  collodion  dressing.  At  the  end  of  six  hours  the  collodion 
is  removed  (with  acetone  or  by  pulling  on  the  gauze),  and  the  patient  urinates. 
Water  is  taken  freely  except  during  the  four  hours  preceding  the  application  of 
the  treatment.  The  meatal  secretion  is  examined  each  day  before  the  injection 
is  administered.  Gonococci  have  usually  disappeared  by  the  third  day.  If 
they  are  still  present  on  the  fifth  day  the  treatment  should  be  abandoned  and 
''systematic  treatment"  instituted. 

The  whole  course  of  treatment  consists  of  five  injections,  on  five  successive 
days,  after  which,  if  successful,  three  days  are  allowed  to  elapse  before  admin- 
istering the  beer  or  other  test  as  a  proof  of  cure. 

SYSTEMATIC  TREATMENT  OF  ACUTE  GONORRHCEA 

To  be  properly  so  characterized,  each  step  of  the  treatment  should  be  car- 
ried out  with  a  definite  purpose  in  view,  the  mode  of  action  of  the  various 
agencies  employed  being  thoroughly  understood,  so  that  empiricism  is  reduced 
to  a  minimum. 

"WTien  one  considers  the  pathology  of  gonorrhoea,  the  manner  in  which  the 
gonococci  become  deeply  buried  in  the  urethral  mucosa,  and  the  inadequacy  of 
the  available  drugs  to  destroy  bacteria  so  buried  without  injuring  to  an  unjusti- 
fiable degree  the  tissues  by  which  they  are  surrounded,  the  futility  of  depending 
upon  the  germicidal  power  of  lotions  at  once  becomes  evident.  The  germicidal 
power  of  the  tissues  is  the  agency  we  must  look  to  to  eliminate,  the  gonococci, 
and  this  power  must  be  maintained  at  its  point  of  greatest  efficiency. 

Gonococci  are  destroyed  by  the  inflammation  they  excite;  inflammation 
of  moderate  degree  exhibits  the  greatest  germicidal  power.  The  therapeutic 
indications  are  met  by  reducing  the  more  severe  grades  of  inflammation,  and  by 
stimulating  those  which  are  indolent. 

The  means  at  our  command  for  the  accomplishment  of  these  purposes 
consist  in  regulation  of  the  patient's  mode  of  fife,  internal  medication,  and 
local  applications.     The  first  and  last  are  the  most  important  methods. 

HYGIENIC   MEASURES 

These  are  of  special  importance  in  the  beginning  of  the  attack,  as  at  this 
time  the  inflammation  is  commonly  too  severe,  and  accordingly  all  factors  which 
tend  to  irritate  the  diseased  parts  are  to  be  avoided. 

Exercise. — Violent  activity  is  injurious  in  two  ways;  by  causing  direct 
traumatism,  and  by  producing  an  irritating  urine.  For  these  reasons  rest  is 
to  be  enjoined,  walking  being  preferred  to  running,  sitting  to  standing;  a 
reclining  posture  for  a  short  time  at  midday  and  in  the  evening,  the  buttocks 
being  elevated,  is  advisable.  Rest  in  bed  is  not  advised  because  it  is  nearly 
always  impracticable,  and  because  it  causes  a  depreciation  in  bodily  vigor. 

Occupation,  Amusements,  etc. — Whatever  causes  the  patient  to  remain  for 
long  periods  of  time  on  his  feet  sTiould  be  forbidden;  if  it  be  impossible  for 
the  patient  to  abandon  an  undesirable  occupation,  its  evil  consequences  should 
be  mitigated  as  far  as  possible  by  means  of  occasional  rests. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   193 

The  patient  should  be  made  to  understand  very  clearly  that  the  hyper- 
semia  engendered  by  even  moderate  sexual  excitement  distinctly  aggravates 
the  inflammation  and  postpones  his  cure;  hence  he  must  avoid  company,  read- 
ing, or  thoughts  which  might  produce  local  congestion. 

Tobacco  is  not  harmful  when  used  in  moderation. 

Sleep. — The  patient  should  sleep  on  a  hard  mattress,  without  too  much 
covering;   good  ventilation  should  be  provided  for. 

For  the  avoidance  of  erections  the  patient  should  sleep  on  his  side;  a 
towel  tied  about  the  waist  with  the  knot  at  the  back  is  an  aid  to  the  main- 


FiG.  101. — Suspensory  of  suitable  design. 

tenance  of  this  position,  or  a  wooden  pill-box  may  be  strapped  to  the  back 
with  adhesive  plaster  for  the  same  purpose.  The  bladder  should  be  emptied 
the  last  thing  before  retiring,  and  once  during  the  night.  A  prolonged  hot 
bath  at  bedtime  is  helpful. 

Diet. — A  simple  diet  is  desirable,  that  which  the  patient's  experience 
has  shown  him  is  best  suited  to  his  needs  and  is  most  readily  digested.  Des- 
serts, highly  seasoned  food,  acid  fruits,  rhubarb,  tomatoes,  cabbage,  Brussels 
sprouts,  alcohol  in  any  form,  and  carbonated  waters  should  be  forbidden. 

Milk  (whole  milk,  skimmed  milk,  or  butter-milk)  may  be  taken  freely 
by  those  with  whom  it  agrees.  The  drinking  of  one  or  two  glasses  of  water 
13 


194  GENITO-URINARY  SURGERY 

before  each  meal,  unless  this  interferes  with  digestion,  is  desirable.  Not  less 
than  two  quarts  of  water  should  be  taken  daily.  Tea  and  coffee  may  be 
taken  in  moderation  by  those  who  have  no  idiosyncrasies  against  them. 

Bowels. — At  least  one  daily  movement  is  essential. 

Dressing. — If  the  foreskin  entirely  covers  the  penis,  the  best  dressings 
are  composed  of  four  thicknesses  of  gauze,  two  inches  wide  by  five  inches  long, 
with  a  diagonal  slit  cut  in  the  middle.  In  applying,  the  central  cut  is  stretched 
sufficiently  to  allow  passage  of  the  glans,  the  foreskin  being  pulled  forward 
over  the  gauze  so  as  to  hold  it  in  place.  If  the  foreskin  is  absent,  the  foot  of 
an  old  stocking,  or  a  bag  of  similar  size  made  out  of  any  thin  material,  may 
be  pinned  to  the  shirt  in  front;  at  the  bottom  of  this  is  placed  a  wad  of 
absorbent  gaaze,  and  the  penis  is  allowed  to  hang  in  the  bag.  The  gonorrhceal 
bag  made  of  thin  permeable  fabric,  provided  with  a  buttoned  flap  which 
can  be  turned  down  readily  and  fastened  as  is  a  suspensory  bandage  around 
the  loins,  is  an  equally  efficient  and  more  convenient  dressing.  Any  dressing 
which  on  removal  is  followed  by  the  immediate  escape  of  one  or  more  drops 
of  discharge,  thus  showing  that  there  is  a  damming  back,  should  be  dis- 
continued. 

The  patient  must  be  cautioned  in  regard  to  the  contagious  nature  of  the 
discharge.  He  should  wash  his  hands  carefully  after  each  handling  of  the 
organ  or  of  the  dressing,  and  should  be  especially  warned  of  the  danger  of 
gonorrhceal  conjunctivitis.  He  should  be  instructed,  in  addition  to  other  pre- 
cautions, to  keep  his  fingers  away  from  his  eyes.  Since  gonococcal  infection 
can  be  carried  by  means  of  towels  in  the  bath,  particularly  to  female  infants, 
the  patient  must  be  informed  of  this  fact. 

The  directions  above  detailed  should  be  given  the  first  time  the  patient 
is  seen.  A  suspensory  should  always  be  worn  during  the  acute  stages  of 
the  disease  (Fig.  101). 

INTERNAL  MEDICATION 

Drugs  are  given  for  the  purpose  of  altering  the  character  of  the  urine,  and 
for  the  relief  of  pain,  spasm,  etc. 

In  the  early  days  of  a  gonorrhcea  the  urethral  mucosa  is  so  sensitive  that 
urine  which  is  at  all  acid  markedly  increases  the  ardor  urinse  which  is  a 
characteristic  symptom.  At  this  time  the  urine  should  be  made  neutral  or 
slightly  akaline  by  the  administration  of  potassium  or  sodium  bicarbonate,  or 
potassium  citrate,  at  least  one  and  a  half  drachms  a  day,  in  three  or  more 
doses,  a  glass  of  water  being  taken  after  each. 

The  combination  of  an  alkaline  diuretic  with  sedatives  to  the  circulatory  and 
nervous  systems  is  often  advisable.     The  following  combinations  are  useful: 

B 

Tinct.    aconiti    ■ TTLxlviii 

Pot.  brom 9 viii 

Pot.   acetat 5ss 

Infus.    pareirfe     q.  s.  ad.  fSviii. 

M.  S.  Tablespoonful  in  water  every  two  hours. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   195 

ft 

Tinct.  verat TTLxxxii 

Pot.  bromid. 

Sod.  bicarb aa  9  viii 

Liq.  pot.   cit q.  s.  ad.  fSviii. 

M.  S.  Tablespoonful  in  water  every  two  hours. 

A  large  number  of  remedies  have  been  employed  for  the  purpose  of  benefiting 
the  mucous  membrane  of  the  urethra,  or  of  killing  the  gonococci  or  preventing 
their  growth.  Unfortunately  all  of  them  are  eliminated  in  such  small  per- 
centages, and  the  medicated  urine  lies  in  contact  with  the  urethral  mucosa 
for  such  a  short  time,  that  the  advantages  derived  from  their  use  are  trifling, 
especially  in  disease  of  the  anterior  urethra.  Sandalwood  oil,  salol,  copaiba, 
and  cubebs  are  of  value  in  about  the  order  named.  The  esters  of  sandal- 
wood, supplied  under  a  number  of  trade  names,  are  potent,  and  often  cause 
less  irritation  than  the  pure  oil.  Boric  acid  is  sometimes  helpful,  especially 
in  inflammation  of  the  posterior  urethra  and  bladder.  A  combination  of 
several  of  the  drugs  often  acts  better  than  any  one  of  them  alone.  The  fol- 
lowing formulae  are  recommended: 

Pbenylis'  salicyl.    (Salol) 

Oleoresinas  cubebse aa  gr.  v 

Copaibse Tr[x 

Pepsin   gr.    i 

B 

Phenyl,  .salicyl gr.   iii 

Ol.  santali 

Copaibse   aa  Tlliii 

01.  Cinnamomi  gtt.   i 

Four  to  six  of  the  former  capsules  or  six  to  ten  of  the  latter  should  be 
taken  during  the  twenty-four  hours.  Copaiba  and  cubebs  should  not  be  given 
during  the  early  part  of  the  disease. 

All  of  the  antiblenorrhagics,  the  balsams  especially,  are  prone  to  cause 
gastric  disturbances.  This  may  be  avoided  in  part  by  administering  them 
after  meals.  Whenever  they  cause  indigestion,  even  of  the  mildest  grade, 
their  use  should  be  discontinued.  Other  disturbances  caused  by  balsamic  medi- 
cation are  pain  in  the  lumbar  region,  hsematuria,  and  albuminuria,  due  to 
renal  irritation;  cutaneous  eruptions  (Fig.  102),  urticarial  or  macular,  may 
occur  in  patients  who  are  taking  copaiba. 

Warm  baths  taken  immediately  before  retiring  are  useful  for  the  pre- 
vention of  erections  during  the  night.  When  these  do  not  suffice,  the  bromides 
(30  to  60  grains),  hyoscyamine  sulphate  (V200  grain),  or  monobromated  camphor 
(2  grains),  may  be  given  during  the  evening. 

For  the  severe  tenesmus  and  strangury  of  acute  posterior  urethritis,  opium 
and  belladonna  should  be  given  by  way  of  the  stomach  or  rectum,  or  their 
alkaloids  injected  hypodermically. 


196 


GENITO-URINARY  SURGERY 


Fig.  102. — Copaiba  eruption. 

LOCAL  TREATMENT 
During  the  acute  stage  of  the  disease  the  local  applications  consist  of  in- 
jections and  irrigations,  the  former  being  administered  by  means  of  a  small 
syringe  (Fig.  103)  to  the  anterior  portion  of  the  urethra,  the  latter  by  means 
of  hydrostatic  pressure  to  both   the   anterior  and  posterior  portions  of  the 


Fig.  103. — Urethral  syringe. 

canal.  In  some  cases  instillations  into  the  posterior  urethra  are  employed. 
Mechanical  manipulations  and  applications  through  the  urethroscope  are  not 
indicated. 

Local  treatment  is  necessary  in  practically  all  cases  of  urethritis;    some 
can  be  cured  by  attention  to  hygiene  and  the  administration  of  internal  reme- 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   197 

dies,  but  the  course  of  the  disease  so  treated  is  longer  and  the  result  is  not 
so  well  assured. 

Treatment  by  Injections. — The  chief  advantage  of  the  injection  method 
of  treatment  lies  in  the  fact  that  it  can  be  easily  carried  out  by  the  patient  in 
his  home.  It  is,  nevertheless,  essential  that  he  be  seen  by  his  physician  at 
frequent  intervals  at  the  beginning  of  the  attack,  at  least  every  other  day,  that 
the  progress  of  the  case  may  be  observed  and  the  treatment  changed  as  condi- 
tions indicate.  At  the  first  visit,  after  the  nature  of  the  disease  has  been 
definitely  determined  by  means  of  the  microscope,  and  the  necessary  hygienic 
precautions  have  been  outlined,  the  patient  should  be  carefully  instructed  in 
the  method  of  sterilizing  and  caring  for  his  syringe,  and  should  then  be  given 


Fig.   104.- 


-Anterior  urethral  injection  by  patient.     The  syringe  is  grasped  by  the  fingers,  and  the 
thumb  is  used  to  push  m  the  piston. 


a  practical  lesson  in  its  use,  syringing  his  anterior  urethra  with  normal  saline 
solution  till  the  surgeon  is  satisfied  that  he  knows  how  the  act  should  be  per- 
formed.    (Fig.   104.) 

At  the  second  and  subsequent  visits  the  meatal  discharge  and  the  freshly 
voided  urine  should  be  inspected,  specimens  being  stained  and  examined  with 
the  microscope  from  time  to  time,  and  according  to  the  course  of  the  disease 
alterations  made  in  the  treatment,  or  the  patient  directed  to  continue  as  before. 
At  the  end  of  a  week  or  ten  days,  if  the  posterior  urethra  has  not  become 
infected  so  that  it  requires  treatment  from  the  physician  in  person,  the  intervals 
between  the  patient's  visits  may  be  gradually  lengthened. 

For  injections  the  apparatus  needful  consists  of  an  aseptible  syringe  with 
a  short  blunt  end,  that  it  may  not  injure  the  urethral  mucosa,  the  capacity 


198  GENITO-URINARY  SURGERY 

being  from  two  to  four  drachms.  The  syringe  may  be  made  of  either  glass  or 
hard  rubber;  the  glass  syringes  (with  asbestos  packing)  may  be  boiledj  hard 
rubber  syringes  should  be  sterilized  in  solutions  of  phenol  or  formaldehyde  (5 
per  cent,  in  either  case). 

In  the  most  acute  cases  only  bland  remedies  should  be  used.  Solutions 
of  sodium  chloride,  1  to  2  per  cent.,  often  act  admirably,  as  do  argyrol,  in 
about  the  same  strength,  or  ichthyol  (1  to  1000).  Hot  general  baths  or 
sitz-baths,  of  ten  to  fifteen  minutes'  duration,  are  of  distinct  advantage  at 
this  stage. 

In  less  inflammatory  conditions  these  same  remedies  may  be  prescribed, 
but  in  greater  strength,  or  other  substances  of  a  more  irritant  nature  may  be 
employed.  The  organic  salts  of  silver  usually  give  the  best  results  when 
injections  are  used.  This  is  probably  not  so  much  on  account  of  their  bac- 
tericidal properties,  which  are  not  great,  but  rather  on  account  of  their  effect 
on  the  urethral  tissues. 

Argyrol  and  protargol  are  the  most  useful  members  of  the  organic-silver 
group.  The  former  is  much  the  less  irritating,  and  should  therefore  be  used 
at  the  beginning  of  the  attack,  in  from  one  to  five,  or  even  ten,  per  cent, 
solution.  Unfortunately  it  stains  whatever  it  touches,  so  that  as  soon  as 
conditions  permit  its  employment  protargol  is  the  preferable  drug.  It  should 
be  used  in  solutions  of  from  J^  to  1  per  cent.  Solutions  of  either  drug  should 
be  injected  and  retained  in  the  urethra  fo«  five  minutes  by  compressing  the 
meatus  three  or  four  times  a  day,  the  injections  being  preceded  by  urination. 
Should  more  than  a  slight  amount  of  pain  be  caused  by  the  injections,  either 
their  strength  or  the  time  of  their  retention  must  be  reduced. 

Potassium  permanganate  is  useful  in  the  injection  treatment  of  gonorrhoea, 
though  it  is  more  often  used  as  an  irrigation.  Its  strength  may  vary  accord- 
ing to  conditions  from  1  :  12,000  to  1  :  1000,  or  even  1:  500;  1  :  4000  is 
the  generally  useful  dilution.  The  best  results  are  secured  with  this  prepara- 
tion when  it  is  used  as  a  sort  of  modified  irrigation,  the  patient  using  a  glass- 
ful of  the  solution  in  repeatedly  syringing  his  anterior  urethra.  When  it  is 
to  be  used  in  this  way  the  following  prescription  may  be  given: 

R 

Potassii  permanganati   gr.   xxiv 

Aquae  q.s.  ad   fSiii 

M.  S.     A  teaspoonful  in  a  glass  of  boiled  water. 

NOTE.^It  is  a  convenience  to  the  physician  and  a  safeguard  to  the  patient 
against  the  prying  eyes  of  his  family  to  simply  number  prescriptions,  writing 
the  directions  in  extenso  on  a  separate  piece  of  paper.  In  case  it  is  desired  to 
have  the  patient  resume  the  use  of  an  earlier  prescription,  the  one  meant  can 
then  be  indicated  to  him  by  its  number  without  danger  of  confusion. 

When  the  discharge  lessens  in  amount,  containing  a  considerable  propor- 
tion of  mucus,  the  use  of  "astringent"  lotions  is  indicated;  at  first  in  combina- 
tion with  the  injections  previously  employed,  substitution  for  one  or  more 
cf  the  injections  being  made  each  day,  and  later  alone.  The  following  formula 
is  useful: 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE   199 

Ext.   hydrast.    fl.    (colorless) fovi 

Bismuthi  subcarb 3vi 

Boroglycerid.    (25   per   cent.) .  3vi 

Aqua;   destil Ev'i 

M.  S.     Inject  after  urination. 

To  this  may  be  added  zinc  sulphocarbolate  in  the  proportion  of  five  grains 
to  the  ounce  of  water,  the  bismuth  being  replaced  by  this  drug  towards  the 
end  of  the  attack  to  enable  the  surgeon  to  determine  the  nature  and  quantity 
of  the  discharge. 

Another  astringent  injection  efficacious  in  the  last  weeks  of  gonorrhoea, 
and  serviceable  at  all  stages,  is  the  well-known  injection  Brou.  This  is  com- 
pounded  as   follows: 

Zinc  sulphatis    gr.   xx 

Plumbi  acetatis    gr.   xx 

Tinct.  opii 

Tinct.  catechu    aa  3ii 

Aquae ad  fBvi 

M.  S.     Use  as  an  injection  after  urination. 

Ultzmann's  injection  is  particularly  efficacious  when  in  the  subsiding  stage 
discharge  ceases  to  diminish  under  other  applications.  The  formula  for 
this  is: 

B 

Zinci  sulphatis 

Pulv.  alum aa  gr.  iv  ad  gr.  xii 

Acidi  carbolici gr.  iv 

Aquse fSvi 

M.   S.     Use  by  injection,   changing   the   strength   in   accordance   with 
the   indications. 

Other  astringent  injections  which  may  be  employed  are: 

Zinci  acetatis 

Acidi  tannici    aa   gr.   xx 

Aquae  rosse   giv 

^        .      . 

Zinci   sulphatis gr.    xv 

Plumbi   subacetatis    gr.   xx 

Aquse   camphorse    fSii 

Aquse   destilatas    f.5iv 

The  cessation  of  treatment  should  be  gradual,  the  number  of  injections 
taken  during  the  course  of  the  day  being  gradually  reduced  during  a  week 
or  ten  days.  Tests  to  demonstrate  the  cure  of  the  condition  should  be  made 
about  a  week  after  the  conclusion  of  the  treatment  and  before  the  .patient  is 
discharged. 

In  many  cases  the  treatment  outlined  above  cannot  be  followed  on  account 
of  the  occurrence  of  posterior  urethritis.  When  this  happens  there  must  be 
sufficient  departure  from  the  method  to  care  for  the  disease  in  this  portion 
of  the  canal  (see  p.  203). 


200 


GENITO-URINARY  SURGERY 


Treatment  by  Irrigations. — In  this  method  of  treatment  the  urethra  is 
washed  with  large  quantities  of  fluid,  the  lotions  being  made  to  enter  the 
anterior  urethra  alone,  or  both  the  anterior  and  posterior  portions  of  the  canal, 
by  means  of  hydrostatic  pressure.  While  it  may  be  carried  out  by  the  patient 
in  his  home,  the  apparatus  used  in  the  treat- 
ment and  the  large  amount  of  water  required 
are  apt  to  excite  attention  and  comment,  so 
that  patients  usually  come  to  the  office  for 
treatment. 

•For  irrigations  the  apparatus  is  almost 
as  simple,  though  bulkier  than  that  used  for 
injections.  It  consists  of  a  reservoir,  a  piece 
of  rubber  tubing,  four  to  six  feet  long,  and  a, 
blunt  nozzle.  For  the  use  of  patients  in  their 
homes  a  rubber  fountain  syringe  (Fig.  105), 
fitted  with  an  appropriate  nozzle,  answers  the 
purpose  in  a  satisfactory  manner,  but  in  the 
office  a  glass  perco- 
lator with  arrangement 
for  raising  and  lower- 
ing, and  a  handle  for 
the  nozzle  provided 
with  some  device  for 
the  control  of  the  flow 
of  the  fluid,  such  as 
that  of  Valentine  (Fig. 
106),  adds  greatly  to 
the  surgeon's  conveni- 

FiG,  105.— Irrigating  bag.     ^^^^ 

Dilute  solutions  of  permanganate  of  po- 
tassium are  the  favorites  in  this  method  of 
treatment.  This  salt,  especially  when  ap- 
plied in  hot  solutions  (112°  to  120°  F.), 
seems  to  have  the  faculty  of  inducing  an 
cedematous  condition  in  the  walls  of  the 
urethra  which  is  inimical  to  the  gonococcus. 
If  this  condition  can  be  maintained  continu- 
ously for  a  period  of  seven  to  ten  days  by 
the  application  of  lotions  of  proper  strength 
at  appropriate  intervals  it  is  possible  to  cure 
acute  attacks  of  the  disease  in  this  length 
of  time.  Unfortunately  it  does  not  seem 
to  be  always  possible  to  produce  this  condition,  or  some  strains  of  the  gonococcus 
are  not  as  susceptible  as  others  to  this  reaction. 

The  treatment  should  be  administered  twice  a  day  for  the  first  four  to 
six  days,  and  thereafter  once  a  day.  Each  day  before  administering  the 
irrigation  the  urine  is  inspected  to  ascertain  the  extent  of  the  involvement  of 


Fig.     106. 


Valentine     irrigator,      as      ar- 
between     treatments     with     tubing- 
across  top  of  ijercolator. 


ranged 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE  20L 

the  urethra;  if  the  anterior  urethra  only  is  affected,  the  irrigation  should 
be  confined  to  this  portion  of  the  canal;  when  clouding  of  the  second  urine 
shows  posterior  disease,  provided  the  symptoms  are  not  too  acute,  weak  solu- 
tions should  be  allowed  to  pass  back  into  the  bladder.  After  the  first  four 
to  six  days  the  treatments  are  given  once  a  day.  By  the  end  of  the  third 
week,  if  cure  has  not  occurred  before  that  time,  intervals  of  two  or  three 
days  may  be  allowed  to  elapse  between  treatments.  Disease  of  the  prostate 
is  a  common  complication  at  this  time,  so  that  this  gland  must  be  considered 
in  the  management  of  the  case. 

The  irrigations  are  administered  in  the  following  manner:  The  reservoir 
is  filled  with  the  lotion  of  choice  and  the  air  expelled  from  the  tubing  by 
elevating  the  nozzle  and  lowering  it  slowly;  the  reservoir  is  then  raised  to  a 
height  of  three  to  five  feet  above  the  patient's  chair.     The  treatments  are 


Fig.  107. — Position  for  irrigation  with  patient  seated. 

most  conveniently  given  with  the  patient  seated  far  forward  on  a  chair,, 
with  his  shoulders  resting  against  the  chair-back  (Fig.  107).  The  trousers 
and  underclothing  should  be  pushed  down  below  the  knees  so  that  when  the 
feet  are  brought  together  the  knees  can  be  separated.  The  patient  holds  a 
basin  below  his  penis  for  the  reception  of  the  escaping  fluid.  The  operator 
seats  himself  on  a  chair  or  stool  at  the  patient's  right,  takes  the  penis  in 
his  left  hand  and  the  nozzle  of  the  irrigator  in  his  right,  and  directs  a  gentle 
stream  against  the  meatus.  While  the  fingers  of  the  left  hand  compress  the 
urethra  at  various  points,  the  tip  of  the  blunt  nozzle  is  introduced  into  the 
meatus,  and  successive  sections  of  the  urethra  are  cleansed  by  allowing  the 
fluid  to  flow  in  and  out.  If  the  apparatus  is  provided  with  a  shield  to  catch 
the  escaping  fluid,  as  in  the  Valentine  apparatus,  the  nozzle  may  be  allowed 
to  lie  loosely  in  the  meatus,  the  fluid  then  escaping  beside  the  nozzle;   even 


202 


GENITO-URINARY  SURGERY 


under  these  circumstances,  however,  the  nozzle  must  be  removed  from  time 
to  time  to  allow  the  urethra  to  completely  empty  itself.  If  the  posterior  urethra 
is  to  be  treated  as  well,  after  the  anterior  portion  has  been  thoroughly  cleansed 
the  nozzle  is  made  to  occlude  the  meatus,  while  the  patient  is  directed  to 
relax  his  muscles  as  though  he  were  about  to  pass  urine.  The  fluid  then 
either  at  once  or  after  the  compressor  muscle  has  become  tired  passes  back 
and  fills  the  bladder. 

Irrigations  may  also  be  given  with  the  patient  lying  down  or  standing 
(Fig.  108).  Some  patients  are  better  able  to  relax  their  muscles  in  one  of 
these  positions  than  when  seated,  and  for  some  the  supine  position  is  prefer- 
able on  account  of  a  tendency  to  syncope.  In  this  position  the  escaping  fluid 
may  be  caught  in  a  shallow  basin  placed  on  the  patient's  thighs,  in  a  douche 


Fig.  108. — Irrigation  of  the  anterior  urethra  with  the  patient  standing. 

pan  placed  beneath  him,  or  by  means  of  special   attachments  incorporated 
in  the  table. 

Solutions. — The  lotions  used  for  irrigation  include  nearly  all  those  used 
in  any  form  of  treatment.  The  most  useful  in  the  majority  of  cases  are 
those  containing  permanganate  of  potash.  At  the  beginning  of  the  treatment 
this  should  have  a  strength  not  greater  than  1  to  4000,  and  often  1  to  12,000 
is  sufficient.  Later  this  strength  may  be  increased,  even  to  1  to  500,  though 
this  is  rarely  of  advantage  and  should  never  be  used  in  the  posterior  urethra 
or  bladder;  in  these  a  concentration  of  1  to  2000  should  rarely  be  exceeded. 
Other  drugs  which  may  be  used  are  sodium  chloride,  from  1  to  4  per  cent.; 
ammonium  sulphichthyolate,  from  1  to  10,000  to  1  to  500;  zinc  permanganate, 
1  to  12,000  to  1  to  1000,  the  effect  being  much  the  same  as  that  of  the  potas- 
sium salt,  but  a  trifle  more  stimulating;  and  silver  nitrate,  from  1  to  20,000 
to  1  to  1000,  this  being  one  of  the  most  valuable  drugs,  to  be  used  when 
others  seem  to  have  lost  their  effect,  when  a  lotion  with  a  strong  antiseptic 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE  203 

action  is  desired,  or  one  which  will  produce  a  pronounced  reaction;  unfor- 
tunately, even  the  weakest  solutions  of  silver  nitrate  sometimes  cause  burning 
which  is  severe  and  protracted. 

ACUTE  POSTERIOR  URETHRITIS 

The  treatment  of  this  condition  varies  with  the  severity  of  the  process. 
As  a  rule,  it  is  better  to  do  nothing  locally  during  the  first  three  or  four  days 
after  the  onset  of  the  infection,  and  if  the  inflammation  be  severe  this  time  may 
be  extended  to  a  week  or  more.  During  this  time  the  patient  should  be 
careful  in  his  observance  of  the  rules  of  hygiene,  should  rest  more  than  he 
was  doing  while  the  inflammation  was  entirely  anterior,  should  keep  his  urine 
bland  by  the  ingestion  of  large  quantities  of  water,  and  should  take  hot  sitz- 
baths  twice  a  day  and  hot  rectal  irrigations  once  a  day.  In  the  more  severe 
cases  bed-treatment  is  advisable. 


Fig.  109.— Posterior  instillation. 

The  local  treatment  consists  in  irrigations;  occasionally  instillations  are 
indicated. 

The  irrigations  are  best  given  with  a  short  urethral  nozzle  in  the  manner 
already  described.  In  exceptional  instances,  in  which  the  patient  is  unable 
to  relax  his  muscles  so  as  to  allow  the  fluid  to  enter,  or  in  which  the  pressure 
of  the  fluid  causes  pain,  a  small  soft-rubber  catheter  may  be  used  for  the 
introduction  of  the  lotion. 

The  solutions  used  when  the  process  is  an  active  one  should  be  the  milder 
of  those  mentioned  (p.  198).  Dobell's  solution,  one-fourth  strength,  also 
acts  well  in  many  cases.  If  they  give  relief,  the  milder  solutions  may  be 
used  frequently,  as  often  as  three  times  a  day. 

Instillations  are  seldom  indicated  in  the  acute  stage  of  the  disease,  but  may 
be  used  when  the  condition  fails  to  improve  under  the  treatment  outlined, 
or  in  presence  of  persistent,  distressing  frequency  of  urination. 

The  treatment  is  administered  by  means  of  an  instillator,  a  silver  or  hard- 
rubber  catheter-like  tube  with  a  very  small  lumen,  fitted  to  a  small  graduated 


204  GENITO-URINARY  SURGERY 

syringe.  The  instrument  is  introduced  till  the  tip  has  passed  the  compressor 
urethrse  muscle  and  lies  in  the  prostatic  urethra,  its  arrival  at  this  point  being 
recognized  sometimes  by  the  sense  of  lessened  resistance,  usually  only  by 
the  direction  of  the  handle  of  the  instillator,  this  making  an  angle  of  about 
70  degrees  with  the  horizontal  when  the  tip  has  arrived  at  the  proper  point 
(Fig.  109). 

Argyrol  (10  per  cent.)  and  silver  nitrate  (1  per  cent.)  are  the  solutions 
most  used.  From  2  to  10  minims  of  either  may  be  applied,  the  desired  quan- 
tity being  instilled  as  slowly  as  possible.  The  immediate  effect  is  usually 
to  increase  the  discomfort,  relief  being  experienced  after  a  variable  length  of 
time. 

CHRONIC   GONORRHCEA 

A  purulent  discharge  lasting  more  than  eight  weeks  is  indicative  of  chronic 
urethritis,  or  gleet.  The  essential,  and  often  the  only,  sign  of  chronic  urethritis 
is  pus.  This  may  be  discharged  from  the  meatus,  particularly  in  the  morning, 
or  may  be  found  only  after  careful  examination  of  the  urine. 

Typical  chronic  gonorrhoeal  urethritis  is  an  inflammation  of  both  the 
anterior  and  posterior  portions  of  the  urethra;  occasionally  the  anterior  urethra 
alone  is  affected;  rarely  the  posterior  portion  is  the  seat  of  the  disease  when 
the  anterior  canal  is  normal. 

The  usual  discharge  is  mucoid  and  whitish  and  quite  small  in  amount, 
sufficient  only  to  stick  together  the  lips  of  the  meatus,  or  to  cause  the  urine 
to  be  slightly  cloudy  or  dotted  with  small  shreds;  less  often  the  secretion  is 
thick  and  yellowish,  or  even  greenish  and  profuse.  It  is  not  uncommon  for 
discharge  at  the  meatus  to  be  entirely  absent,  its  presence  being  only  detected 
by  examination  of  the  urine. 

Undue  frequency  and  urgency  of  urination,  signs  of  posterior  involvement, 
may  be  scarcely  noticeable  or  harassing  and  crippling  in  severity. 

Burning  and  stinging  during  urination,  sometimes  after  the  act,  may  also 
be  present.  The  sensation  is  usually  felt  in  the  perineum,  or  it  may  be  felt 
at  the  bladder  neck,  or  about  an  inch  from  the  end  of  the  penis. 

Symptoms  of  a  sexual  character,  as  priapism,  sexual  irritability,  premature 
ejaculations,  etc.,  are  often  associated  with  chronic  posterior  urethritis,  but 
it  is  often  difficult  or  impossible  to  determine  whether  they  are  due  to  the 
urethritis  or  to  a  concomitant  prostatitis. 

The  course  of  chronic  urethritis  is  usually  somewhat  varied,  being  marked 
at  irregular  intervals  by  sudden  exacerbations.  Thus  the  chronic,  indolent, 
posterior  catarrh  may  be  rendered  subacute  or  even  acute  by  very  slight 
causes,  such  as  exposure  to  cold,  moderate  drinking,  or  coitus.  The  inflam- 
mation then  extends  forward  to  the  bulbous  urethra  and  there  is  a  more 
or  less  free  discharge,  often  associated  with  slight  urgency  and  undue  fre- 
quency of  micturition.  These  symptoms  subside  quickly  and  are  usually  at- 
tributed to  a  mild  cystitis. 

Etiology. — The  factors  preventing  the  early  cure  of  gonorrhoea,  causing 
it  to  become  chronic,  and  tending  to  perpetuate  its  existence,  relate  either  to 
the  treatment  of  the  case,  to  peculiarities  of  the  patient,  including  the  infec- 
tion of  paraurethral  structures,  or  the  virulence  of  the  infecting  organism. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE  205 

Either  too  much  or  too  little  treatment  may  be  the  cause  of  failure,  the 
former  because  the  tissues  are  traumatized  and  are  stimulated  to  a  too  great 
reaction  or  beyond  their  power  to  react,  the  latter  through  failure  to  provoke 
the  antibacterial  powers  of  the  tissues;  or  failure  may  be  due  to  the  pa- 
tient's neglect  of  the  hygienic  regulations  prescribed.  It  is  a  not  uncommon 
occurrence  for  a  patient,  considering  himself  cured,  or  nearly  so,  to  bring 
on  a  recrudescence  by  alcoholic  indulgence  or  sexual  excitement. 

The  second  group  contains  the  most  potent  causes  for  the  persistence  of 
urethral  discharge.  Phimosis  of  marked  degree,  reduction  in  the  size  of  the 
meatus,  especially  below  24  F.,  and  stricture  interfere  with  the  drainage  of 
the  canal  and  with  efficient  treatment.  Hypospadia  and  epispadia  tend  to 
prolong  an  infection  because  of  the  narrow  opening  and  the  abundance  of 
paraurethral    crypts   and   glands.      Systemic   diseases   and  derangements   act 


Fig.  110  . — Paraurethral  sinus  at  meatus. 

either  by  reducing  the  vital  resistance  of  the  urethral  tissues  or  by  the  pro- 
duction of  an  irritant  urine;  syphilis  seems  to  act  in  the  former  manner; 
diabetes  and  gout  probably  have  a  double  mode  of  action;  phosphaturia  and 
oxaluria  may  render  a  urethritis  incurable. 

The  infection  of  paraurethral  structures  is  probably  most  frequently  the 
cause  of  the  persistence  of  urethritis.  The  structures  in  which  such  infec- 
tion is  found,  in  the  order  of  frequency,  are  the  prostate,  seminal  vesicles, 
the  glands  and  follicles  of  the  urethra,  including  Cowper's  glands,  paraurethral 
sinuses  (Fig.  110),  preputial  follicles,  the  kidney  pelves,  the  ureters,  and 
possibly  the  bladder. 

Certain  strains  of  the  gonococcus  appear  to  be  more  virulent  than  others, 
and  to  produce  urethritis  which  is  more  difficult  to  cure.  Usually,  however, 
unless  paraurethral  structures  are  attacked,  the  disease  is  merely  more  in- 
flammatory in  type  and  of  slightly  longer  duration.  Unfortunately  this  type 
of  infection  is  prone  to  involve  the  prostate  to  a  serious  degree,  even  if  the 
other  structures  escape. 


206  GENITO-URINARY  SURGERY 

Prognosis. — The  ease  or  difficulty  with  which  chronic  urethritis  can  be 
cured  depends  upon  the  character  of  the  underlying  cause  of  the  condition. 
It  is  therefore  impossible  to  make  any  prognosis  till  a  thorough  examination 
has  revealed  wherewith  one  is  dealing.  Even  in  the  absence  of  periurethral 
and  paraurethral  structural  changes  and  infections,  chronic  inflammation  of 
the  urethra  is  frequently  unexpectedly  difficult  to  cure,  so  that  great  caution 
should  be  used  in  promising  an  early  recovery. 

Diagnosis. — Chronic  urethritis  is  recognized  by  the  finding  of  pus  which 
has  been  secreted  by  the  urethral  mucosa.  Pus  present  at  the  meatus  neces- 
sarily comes  from  the  urethra,  unless  there  be  some  other  obvious  source — e.g.,  a 
periurethral  abscess.  Pus  found  in  the  urine  may  come  from  the  urethra 
or  from  some  other  point  along  the  urinary  tract,  the  differentiation  being 
made  in  part  from  the  symptoms  presented  and  in  part  by  elimination  of 
uninfected  organs.  Reference  to  the  table  on  page  207  will  be  found  helpful 
in  making  the  diagnosis. 

The  determination  of  the  portion  of  the  urethra  which  is  diseased  is 
made  by  means  of  the  "  glass  test  "  described  in  Chapter  II  (see  p.  14). 

One  of  the  most  difficult  matters  connected  with  the  diagnosis  of  chronic 
urethritis  consists  in  the  differentiation  of  gonococcal  from  nongonococcal 
inflammations.  Even  when  gonococci  are  present  in  the  tissues  of  the  urethra 
they  are  not  always  present  in  the  discharge,  and  when  they  are  present  it 
may  be  in  such  small  numbers  that  their  detection  is  extremely  difficult.  In 
such  cases  it  is  only  by  repeated  careful  examinations,  some  of  which  are 
made  after  the  injection  of  irritant  lotions,  as  silver  nitrate,  from  1  :  1000  to 
1  :  100,  that  an  opinion  can  be  formed. 

TREATMENT  OF  CHRONIC  URETHRITIS 

Briefly  stated,  the  treatment  of  chronic  urethritis  consists  of  (1)  the 
recognition  and  removal  of  the  underlying  cause  of  the  condition,  and  (2)  the 
treatment  of  the  urethral  inflammation.  For  the  sake  of  greater  convenience, 
all  of  these  subjects  \vill  be  considered  in  the  present  section. 

Order  of  Procedure. — 1.  Determination  of  the  source  of  discharge, 
whether  from  the  anterior  or  posterior  portion  of  the  urethra,  by  means  of 
the  tests  described  in  Chapter  II  (p.  14),  and  of  its  cellular  and  bacterial 
content. 

2.  Examination  to  determine  the  local  lesions  responsible  for  the  perpetua- 
tion of  the  condition,  if  any  such  exist.  The  nature  of  the  examination  varies 
according  to  the  portion  of  the  urethra  affected. 

A.  Anterior  Urethritis. — Examination  of  the  region  of  the  meatus  and' 
of  the  glans  and  prepuce  for  the  presence  of  paraurethral  sinuses  or  infected 
follicles.  The  follicles  are  usually  found  in  the  coronary  sulcus,  or  in  the 
inner  layer  of  the  prepuce.  Paraurethral  sinuses  or  passages  are  constantly 
present  in  cases  of  hypospadia  and  occasionally  in  normally  developed  indi- 
viduals. Their  favorite  point  of  opening  is  near  the  dorsal  commissure  of 
the  meatus;  in  hyposnadiacs  several  of  them  may  exist  along  the  groove  of  the 
incomplete  portion  of  the  urethra,  or  they  may  exist  at  the  sides  of  the  orifice. 
Their  depth  varies  from  a  fraction  of  an  inch  to  several  inches. 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE  207 


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208  GENITO-URINARY  SURGERY  » 

Exploration  of  the  urethra  for  stricture  (see  Chapter  XIV). 

Palpation  of  the  urethra,  distended  by  a  sound,  for  the  detection  of  in- 
fected follicles,  these  when  filled  with  secretion  giving  the  sensation  of  small 
shot  or  beads. 

Performance  of  anterior  urethroscopy.  This  should  be  a  part  of  the 
routine  procedure  in  the  examination  of  cases  of  chronic  anterior  urethritis,  as 
it  is  a  nontraumatizing  operation,  and  may  yield  valuable  information. 

B.  Posterior  Urethritis. — Examination  of  the  prostate  and  seminal  vesicles, 
expressing  and  examining  their  secretions. 

Exploration  for  stricture. 

Posterior  urethroscopy  is  only  to  be  done  after  an  adequate  trial  of  the 
ordinary  lines  of  treatment  has  proved  unavailing,  as  it  can  usually  be  dis- 
pensed with  altogether  and  can  rarely  be  conducted  without  inflicting  some 
traumatism. 

C.  Anteroposterior  Urethritis. — All  that  has  been  said  under  the  two  pre- 
ceding heads  applies  to  this  condition.  The  most  common  underlying  conditions 
are  prostatitis,  seminal  vesiculitis,  and  stricture. 

Of  the  conditions  mentioned  as  complicating  chronic  urethritis,  stricture, 
prostatitis,  and  seminal  vesiculitis  are  considered  in  separate  chapters. 

Preputial  folliculitis  is  rarely  a  cause  of  recurrent  attacks  of  urethritis. 
When  the  condition  can  be  removed  by  circumcision  this  operation  should  be 
performed.  "V\nien  this  is  impracticable,  the  choice  lies  between  laying  the 
tracts  open  with  the  knife,  cauterizing  them  with  the  galvanocautery,  destroy- 
ing their  epithelium  with  the  electric  needle  (using  the  negative  pole  and  about 
five  milliamperes  of  current  for  half  a  minute  to  a  minute),  or  by  the  injec- 
tion of  cauterant  solutions  {e.g.,  silver  nitrate,  5  to  10  per  cent.). 

Paraurethral  sinusitis  is  treated  in  much  the  same  way.  The  object  is  to 
destroy  the  tract,  either  by  making  it  a  part  of  the  urethra  or  causing  its 
obliteration,  or,  this  failing,  to  overcome  its  infection.  In  treating  these  struc- 
ures  with  cauterant  solutions,  the  possibility — indeed,  the  probability — of  their 
opening  into  the  urethra  must  be  kept  in  mind,  lest  damage  be  done  to  the 
urethral  mucosa.  When  tracts  of  this  nature  cannot  be  treated  without  re- 
sort to  the  injection  of  fluids,  these  must  be  of  a  kind  tolerated  by  the  urethra. 

Folliculitis  Urethralis. — This  condition  may  sometimes  be  overcome  by 
massaging  the  urethra  over  a  sound,  or  by  passing  a  full-sized  bougie  a  boule, 
sometimes  only  by  direct  applications  through  the  urethroscope.  The  passage 
of  instruments  and  massage  should  be  performed  not  oftener  than  once  in 
three  days;  the  object  of  the  treatment  is  to  express  the  morbific  contents  and 
stimulate  repair  by  increasing  the  blood  supply.  The  urethroscopic  treat- 
ment consists  of  incisions  to  assist  drainage,  cauterization  with  the  galvano- 
cautery^, and  destruction  with  the  electrolytic  needle.  In  those  cases  in  which 
a  hollow  needle  can  be  inserted  into  a  follicle  the  treatment  may  be  carried 
out  by  injecting  a  drop  of  a  strong  solution  of  silver  nitrate. 

Urethral  adenitis  is  treated  on  the  same  general  principles  as  folliculitis. 

Treatment  of  the  Urethral  Infection. — Associated  with  the  super- 
ficial, catarrhal  inflammation  in  practically  every  case  there  is  in  addition  an 
infiltration  of  the  deeper  tissues.     This  must  therefore  be  taken  into  account 


AFFECTIONS   CHARACTERIZED  BY  URETHRAL  DISCHARGE  209 

in  applying  treatment  for  chronic  urethritis.  These  infiltrations  are  amenable 
in  but  slight  degree  to  applications  to  the  surface  of  the  urethra,  being  most 
effectively  reached  by  means  of  a  moderate  degree  of  pressure  appHed  by  means 
of  sounds  and  dilators  introduced  into  the  urethra. 

The  use  of  dilatation  is  founded  on  the  fact  that  pressure  on  the  walls  of 
the  urethra  exerts  a  profound  influence  on  the  condition  of  the  subepithelial 
tissues.  It  is  not  necessary  that  the  pressure  be  great,  and  violent  pressure  is 
never  permissible.  All  that  is  necessary  for  the  production  of  a  proper  reac- 
tion is  that  the  instrument  fit  the  urethra  snugly.  If  the  ordinary  steel  sound 
will  do  this,  it  is  the  instrument  that  should  be  used.  On  account  of  the 
irregular  calibre  of  the  urethra,  the  meatus  being  usually  the  smallest  part 
of  the  whole  canal,  unless  the  infiltrations  occur  at  points  of  physiological 
narrowing,  it  is  not  possible  for  a  cylindrical  instrument  of  fixed  size  to  com- 
pletely fill  the  canal  at  the  desired  points.  For  this  reason  dilators  whose 
size   may  be   changed   at   will   have  been   devised,   the  best  being   those  of 


Fig.  111. — Kollmann  posterior  dilator  in  use. 


Kollman.  A  straight  dilator  for  the  anterior  urethra  and  a  curved  instrument 
for  the  prostatic  and  bulbous  portions  are  the  most  useful  models. 

Dilatations  are  practised  not  oftener  than  twice  a  week,  an  interval  be- 
tween treatments  being  required  for  reaction  to  subside.  Dilatation  is  not 
a  stretching;  it  is  rather  a  method  of  mechanical  therapeusis  whereby  old 
inflammatory  infiltrations  are  made  to  disappear  through  a  reaction  in  the 
tissues. 

The  technique  of  dilatations  by  means  of  cylindrical  instruments  consists 
in  the  introduction  of  a  thoroughly  lubricated  sound  or  flexible  bougie  and 
allowing  it  to  remain  in  place  for  about  five  minutes.  Usually  two  instruments 
differing  from  one  another  by  one  or  two  sizes  are  passed  (see  p.  263).  In 
the  case  of  adjustable  dilators,  the  instrument  is  introduced  closed  to  the 
desired  point  and  held  steadily  in  this  position  with  the  left  hand  while  the 
right  turns  the  milled  wheel  on  the  handle  till  the  dial  registers  the  desired 
size  (Fig.  111).  The  point  of  maximum  dilatation  should  be  approached 
14 


210 


GENITO-URINARY  SURGERY 


slowly,   half  a  size   at   a   time,   thereby   accomplishing  what  is   desired   with 
the  least  possible  discomfort  to  the  patient. 

Copious  irrigations  are  the  most  frequently  indicated  form  of  treatment 
in  chronic  urethritis,  not  excepting  dilatations.  They  may  constitute  the  sole 
treatment  of  the  case,  or  may  be  merely  an  auxiliary  to  other  forms  of  thera- 
peusis,  as  dilatations  or  instillations.  Practically  any  drug  may  be  used  for 
the  washings,  but  the  most  useful  and  most  used  are  potassium  permanganate 
and  silver  nitrate.  The  frequency  of  their  application  varies,  according  to 
conditions  and  the  progress  of  the  case,  from  once  a  day  to  once  a  week,, 
the  more  acute  cases  requiring  treatment  at  shorter  intervals  than  the  more 
chronic.  The  strength  of  the  solutions  must  also  be  varied  according  tO' 
circumstances  and  the  effect  desired.     As  a  rule,  the  weaker  solutions  do  the 


Fig.  112. — 'Anterior  urethral  injection. 

most  good,  e.g.,  1  :  4000  permanganate  or  1  :  10,000  silver  nitrate,  but  when 
a  pronounced  reaction  is  called  for  much  stronger  solutions  may  be  used,  the 
silver  salt  being  the  one  of  choice,  in  solutions  up  to  1  :  1000  or  even  1  :  500. 
The  stronger  solutions  may  be  used  either  after  a  gradual  approach  with  solu- 
tions of  increasing  strength,  or  the  change  may  be  made  suddenly,  use  of 
the  weaker  solutions  then  being  resumed  till  the  reaction  excited  shall  have 
subsided.  Whatever  the  method  of  procedure,  the  object  of  ajl  treatment,  the 
production  of  a  suitable  state  of  reaction  in  the  tissues,  must  be  constantly 
kept  in  mind. 

Injections,  used  by  the  patient  at  home  or  given  by  the  physician  in  his 
office  (Fig.  112),  are  very  valuable  in  the  treatment  of  anterior  urethritis. 
For  home  use  the  injections  mentioned  as  appropriate  for  the  subsiding  stage 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE  211 

of  acute  urethritis  may  be  employed.  In  the  office  similar  preparations  may 
be  used,  or  more  powerful  remedies  may  be  applied.  Here  again  silver  nitrate 
is  supreme  and  may  be  used  in  strengths  up  to  1  per  cent.  These  injections, 
given  once  in  two  or  three  or  four  weeks,  are  sometimes  almost  magical  in 
the  results  obtained;  they  are  particularly  applicable  in  cases  of  mixed  in- 
fection. 

Instillations  are  to  the  posterior  urethra  whatinjections  are  to  the  anterior. 
Strong  solutions  are  usually  used,  deposited  in  three-  to  ten-drop  doses,  by 
means  of  an  instillator,  just  back  of  the  compressor  muscle,  the  desired  result 
being  the  production  of  a  powerful  reaction.  Silver  nitrate,  0.5  to  3  per  cent.; 
protargol,  1  to  10  per  cent.,  and  copper  sulphate,  1  to  5  per  cent.,  are  prepara- 
tions used  in  this  manner.  Instillations  should  not  be  made  oftener  than 
twice  a  week. 

Ointments  may  be  used  in  either  the  anterior  or  posterior  portions  of 
the  canal  for  the  purpose  of  producing  medication  through  long  periods  of 
time.  Traces  may  still  be  found  after  a  lapse  of  three  or  four  days.  They 
may  be  used  either  to  soothe  and  protect  the  mucosa  or  to  stimulate  it.  Lano- 
lin is  the  best  base  for  urethral  ointments,  the  other  ingredients  being  selected 
according  to  the  purpose  for  which  the  ointment  is  employed.  The  following 
ointment,  suggested  by  Janet,  is  of  the  bland,  protective  type: 

Sodii  boratis    gr.  x  (2  per  cent.) 

Zinci  oxidi   gr.  xl  (8  per  cent.) 

Lanolin q.s.   ad.   Ei 

The  more  irritant  drugs  may  be  used  in  rather  greater  concentration  in 
ointments  than  in  water  solutions;  thus  from  0.5  to  2  per  cent,  of  silver 
nitrate  may  be  used,  or  from  2  to  5  per  cent,  of  protargol.  For  cases  in  which 
there  is  marked  cornification  or  leucoplasia  of  the  mucosa,  salicylic  ointment, 
0.5  to  1  per  cent.,  may  be  used.  Other  useful  drugs  which  may  be  used  in  this 
manner  are  copper  sulphate  (0.5  to  2  per  cent.),  zinc  sulphate  (1  to  3  per 
cent.),  and  iodoform  (10  per  cent.).  Iodine  may  be  used  in  the  following 
combination: 

lodi gr.   ii  to  iv 

Potassii  iodidi ■. gr.   xx 

Lanolin    • 5i 

Ointments  should  be  dispensed  in  collapsible  tubes.  A  conical  nozzle  which 
can  be  screwed  directly  to  the  tube  then  forms  a  convenient  and  efficient 
means  of  transferring  it  to  the  anterior  urethra,  the  salve  being  then  dis- 
tributed by  stripping  it  along  with  the  fingers.  A  rather  large  wad  of  cotton 
should  be  bandaged  over  the  meatus  to  prevent  soiling  the  clothing.  For 
deposition  in  the  posterior  urethra  an  instrument  somewhat  similar  to  the 
tube  of  an  instillator,  but  with  multiple  fenestrse,  should  be  used,  the  handle  being 
a  reservoir  for  the  ointment,  fitted  with  a  threaded  plunger  for  its  expulsion  (see 
Figs.  9  and  10). 


212 


GEXITO-URIXARY  SURGERY 


Heat  and  Cold. — These  physical  agencies  can  sometimes  be  used  to  great 
advantage.  Heat,  if  applied  in  sufficient  degree  and  for  a  sufficient  length  of 
time,  has  the  power  of  killing  bacteria  in  the  tissues,  and  also  of  producing 
an  inflammator\'  reaction.  To  have  any  bactericidal  power,  a  temperature 
in  excess  of  US'"  F.  must  be  maintained  for  upwards  of  half  an  hour.  This 
is  intolerable  to  many  patients,  even  when  a  local  anaesthetic  has  first  been 
applied.     Cold  (that  is,  a  temperature  from  40°  to  70°  F.)   acts  only  by  its 


Fig.  113. — Treatment  of  chronic  urethritis  with  heated  instruments.  The  patient 
is  holding  the  supply  tube,  and  can  control  the  rate  of  flow  and  thereby  the  temperature 
of  the  water  in  the  sound.  An  infusion  thermometer  indicates  the  temperature  of  the 
water  entering  the  sound. 


The 


stimulant  effect  on  the  tissues;   it  is  not  complained  of  by  the  patient, 
duration  of  the  treatments  should  be  from  ten  to  twenty  minutes. 

WTiich  agency  is  the  more  valuable  in  a  given  case  usually  has  to  be 
determined  by  trial.  In  either  case  the  treatment  may  have  to  be  continued 
for  a  considerable  period;  six  months  or  a  year  is  sometimes  required.  The 
frequency  of  the  treatments  varies  from  twice  a  week  to  once  in  two  weeks; 
an  interval  of  a  week  is  generally  most  appropriate. 

Either  heat  or  cold  can  be  applied  with  a  very  simple  apparatus,  consist- 


AFFECTIONS  CHARACTERIZED  BY  URETHRAL  DISCHARGE  213 

ing  of  a  reservoir  filled  with  water  at  the  desired  temperature,  a  piece  of 
rubber  tubing  leading  to  a  double-current  sound,  or  psychrophore,  and  a 
second  piece  of  tubing  leading  to  a  bucket  on  the  floor  to  receive  the  escaping 
water  (Fig.  113).  The  psychrophore  is  the  only  part  of  the  apparatus  that 
need  be  sterilized.  An  infusion  thermometer  placed  in  the  tube  just  above 
the  psychrophore  is  a  convenience  when  heat  is  used.  The  flow  of  the  solution 
is  regulated  by  pinching  the  supply  tube  with  a  clamp  or  by  means  of  a  stop- 
cock. If  the  patient  is  allowed  to  hold  the  supply  tube  he  can  stop  the  flow 
should  the  temperature  become  too  great  for  endurance,  thereby  giving  him 
a  certain  amount  of  additional  confidence. 

Bacterin  and  Serum  Therapy. — These  agencies  have  not  given  sufficiently 
good  results  in  the  treatment  of  urethral  conditions  to  warrant  their  routine 
employment. 

THE  QUESTION  OF  CURE 

One  of  the  greatest  difficulties  in  the  management  of  a  case  of  gonorrhoea 
is  to  determine  when  the  patient  has  been  cured;  yet  it  is  a  most  important 
matter,  not  only  to  the  patient  himself,  but  to  those  with  whom  he  may 
have  sexual  relations. 

There  are  two  great  classes  of  cases  in  which  this  matter  comes  up  for 
decision.  The  first  class  consists  of  those  in  whom  there  seems  to  have 
been  a  complete  restoration  to  the  normal,  in  which  every  examination  fails 
to  show  the  least  sign  of  disease.  These  cases  may  be  pronounced  cured  after 
the  second   negative   test. 

The  second  class  consists  of  those  who  still  have  shreds  in  their  urine, 
possibly  a  small  mucoid  drop  at  the  meatus  on  waking  in  the  morning,  and 
whose  prostatic  secretion  still  contains  an  excess  of  leucocytes.  Under  such 
circumstances  the  giving  of  a  proper  verdict  may  be  a  matter  of  extreme 
difficulty,  for  we  know,  on  the  one  hand,  that  gonococci  may  lurk  in  the 
depths  of  the  tissues  for  several  years — just  how  many  we  do  not  know — and, 
on  the  other  hand,  that  it  is  possible  for  a  chronic  urethritis,  prostatitis,  etc., 
to  persist  for  months  and  years  after  all  gonococci  have  been  destroyed.  The 
finding  of  pus  in  the  urine  or  in  the  prostatic  secretion  is  therefore  not  con- 
vincing evidence  that  gonococci  are  present,  yet  it  indicates  the  possibility, 
even  the  probability,  of  the  presence  of  these  organisms,  and  it  is  only  after 
prolonged,  yet  futile,  search  on  at  least  six  different  occasions,  with  the  con- 
firmative evidence  of  a  negative  gonococcus  complement-fixation  test,  that  a 
certificate  of  health  may  be  given.  In  coming  to  a  decision  in  such  a  case 
it  is  proper  to  take  into  consideration  the  probable  length  of  time  since  the  last 
infection  ("probable,"  because  patients  are  not  always  accurate  in  their  state- 
ments concerning  such  matters),  for,  while  we  do  not  know  the  extreme 
limits  of  viability  of  the  gonococcus  in  a  single  host,  it  is  certainly  excep- 
tional for  an  infection  to  last  more  than  two  or  three  years. 

The  examination  to  which  the  patient  should  be  submitted  to  determine 
his  state  of  health  should  consist,  first,  of  a  search  for  pus  from  the  urethra 
or  adjacent  organs,  especially  the  prostate  and  seminal  vesicles,  in  order  to 
determine  the  health  of  these  organs,  and,  second,  if  pus  be  found,  of  a  careful 


214  GENITO-URINARY  SURGERY 

scrutiny  of  these  exudates  to  ascertain  their  bacterial  content.  When  urethral 
pus  is  present,  that  first  examined  should  be  taken  from  the  meatus  or  from 
the  urine  if  it  only  appears  in  this  fluid;  on  subsequent  occasions  it  should 
also  be  taken  from  the  shoulder  of  a  bougie  a  boule.  Several  of  the  exami- 
nations should  be  made  about  twelve  hours  after  treatment  with  nitrate  of 
silver,  so-called  "provocative"  injections  and  instillations  being  made  of  solu- 
tions of  from  1  to  1000  to  1  to  100  into  the  anterior  and  posterior  portions 
of  the  canal,  and  others  after  the  patient  has  partaken  freely  of  alcohol. 

The  examinations  of  the  secretions  of  the  prostate  and  seminal  vesicles 
must  be  made  from  specimens  secured  by  massaging  and  stripping  these  organs 
as  described  in  the  chapters  on  "Prostatitis"  and  "Vesiculitis."  Gram's  method 
of  staining  should  be  used  in  the  examination  of  all  suspicious  forms. 

The  complement-fixation  test,  based  on  the  same  principles  as  other 
tests  of  a  similar  nature,  when  performed  by  a  man  experienced  in  this  kind 
of  work,  using  an  antigen  made  up  from  a  number  of  different  strains  of 
gonococci,  is  a  valuable  addition  to  our  means  of  determining  when  a  patient 
has  been  cured.  As  the  test  never  becomes  positive  till  four  to  six  weeks  after 
the  onset  of  the  infection,  it  is  useless  in  the  early  stages  of  the  disease. 
But  when  the  gonococci  have  invaded  the  deeper  tissues  the  test  is  usually 
positive,  and  it  then  remains  positive  till  after  the  gonococci  have  been  elimi- 
nated, probably  for  several  weeks  after  that  time,  so  that  in  the  later  stages 
of  the  disease  a  negative  test,  and  especially  a  negative  test  obtained  after 
the  reaction  has  been  positive,  is  a  valuable  piece  of  evidence. 


CHAPTER  XI 

GONORRHOEA  IN  WOMEN  AND  CHILDREN 

GONORRHCEA  IN  WOMEN 

Frequency  of  the  Disease. — Leaving  aside  the  consideration  of  harlots, 
practically  all  of  whom  suffer  from  some  of  the  acute  or  chronic  forms  of  the 
disease,  gonorrhoea  attacks  a  large  number  of  reputable  women.  The  gloomy 
Noeggerath  states  that  eighty  per  cent,  of  women  are  affected  with  latent  gon- 
orrhoea, while  Sanger  found  that  of  nineteen  hundred  and  thirty  women  coming 
to  his  clinic  twelve  per  cent,  had  this  disease.  Young  married  women  become 
infected  because  long-standing  gleet  in  man  has  not  been  regarded  as  a  bar  to 
matrimony.  The  symptoms  of  gonorrhoea  in  women  may  be  so  slight  as  not  to 
be  attributed  by  the  patient  to  any  cause  more  serious  than  a  cold,  a  strain, 
the  traumatism  of  the  defioweration,  or  some  irregularity  in  her  periodical  sick- 
ness, and  hence  treatment  is  often  neglected. 

Seat  of  Infection. — In  women,  as  in  men,  the  urethra  is  most  frequently 
involved  in  the  gonorrhoea!  inflammation.  Next  in  order  of  frequency  comes 
the  mucous  membrane  of  the  cervix,  then  that  of  the  uterus,  and  finally  that 
of  the  Fallopian  tubes. 

Vaginitis,  at  least  that  directly  due  to  the  gonococcus,  is  extremely  rare,  except 
in  children,  and  possibly  in  young  women  recently  deflowered. 

Vulvitis  is  not  uncommon,  and  is  often  accompanied  by  inflammation  of 
the  glands  of  Bartholin. 

Contagion. — As  in  the  male,  gonorrhoea  is  acute  or  chronic.  Though  it 
is  usually  conveyed  during  sexual  intercourse,  the  possibilities  of  mediate  con- 
tagion through  bathing-water,  garments,  towels,  etc.,  are  much  greater  in  women 
than  in  men. 

In  girl  babies  the  disease  is  nearly  always  acquired  by  mediate  contagion. 
The  discharge  is  derived  sometimes  from  a  gonorrhoea!  ophthalmia,  generally 
from  the  genital  tract  of  the  mother.  Only  very  exceptionally  is  the  contagion 
immediate  and  from  criminal  practices. 

Acute  gonorrhoea  is  usually  acquired  from  the  discharge  of  an  acute  case, 
though  there  can  be  no  doubt  that  chronic  gonorrhoea  in  the  male  may  excite 
a  florid  attack  in  the  female.  Gleety  discharges,  if  contagious,  sometimes 
give  rise  to  a  subacute  attack. 

Symptoms. — The  symptoms  of  acute  gonorrhoea  are  at  the  beginning 
usually  those  of  acute  vulvitis  and  urethritis;  in  children  and  young  girls  there 
is  also  an  acute  vaginitis. 

The  patient  complains  of  a  sense  of  heat  and  burning  about  the  genitalia, 
of  profuse  purulent  discharge,  of  ardor  urinae,  and  of  urgency  and  frequency 
of  micturition. 

If  the  uterine  mucous  membrane  is  also  involved  there  are  usually  marked 
constitutional  symptoms,  i.e.,  fever  and  depression,   and,  in  addition,   severe 

215 


216  GEXITO-URIXARY  SURGERY 

pains  in  the  uterine  region,  swelling  of  the  womb,  and  bloody  purulent  dis- 
charge from  it.  Xot  infrequently  perimetritis  compHcates  the  uterine  inflam- 
mation. 

An  examination  shows  the  mucous  membrane  of  the  vulva  and  sometimes 
that  of  the  vagina  infiltrated,  reddened,  and  eroded.  Pus  can  be  milked 
from  the  urethra. 

The  subacute  gonorrhoea  sometimes  acquired  from  chronic  gonorrhoea  of 
the  male  rarely  shows  itself  by  pronounced  typical  symptoms.  There  are 
intermittent  attacks  of  slight  ardor  urinse,  frequency  of  micturition,  disorders 
of  menstruation,  pelvic  pains,  and  disturbances  in  the  uterine  function,  mani- 
fested by  dysmenorrhcea,  by  sterility,  by  abortion,  and  by  attacks  of  peri- 
metritis, salpingitis,  ovaritis,  or  local  or  general  peritonitis.  The  patients  grad- 
ually lose  their  health,  become  unfit  for  work  of  any  kind,  and  are  prone  to 
develop  into  typical  neurasthenics. 

On  examination  there  will  usually  be  found  a  catarrhal  condition  of  Bar- 
tholin's glands  and  of  the  periurethral  follicles.  Purulent  secretion  escapes 
from  the  cervical  canal,  which  is  sometimes  eroded.  The  uterus  is  found 
enlarged,  tender  on  pressure,  and  fixed  from  attacks  of  perimetritis.  The 
ovaries  and  tubes  are  often  enlarged,  displaced,  and  fixed. 

Diagnosis. — In  the  ordinary  acute  case  this  is  not  difficult,  since  the 
symptoms  themselves  are  almost  characteristic,  and  the  detection  of  the  gono- 
coccus  will  at  once  settle  the  nature  of  the  attack. 

The  subacute  form  is  sometimes  extremely  difficult  to  diagnose,  since  the 
gonococcus  may  not  be  found.  According  to  Sanger,  in  arriving  at  such  a 
diagnosis  careful  search  should  be  made  for  acute  or  chronic  gonorrhoea  in 
the  husband,  or  a  history  of  gonorrhoea  subsequently  cured.  The  presence 
of  gonorrhoeal  ophthalmia  in  children  is  highly  suggestive. 

Matters  of  diagnostic  import  are:  a  history  of  uterine  catarrh  without 
ob\dous  cause;  disease  of  Bartholin's  glands,  and  especially  redness  of  the 
skin  surrounding  their  ducts;  the  presence  of  condylomata;  the  discharge  of 
muco-purulent  matter  from  the  cervix  without  erosions  or  pseudo-erosions  of 
the  os;  disease  of  the  adnexa  or  of  the  pelvic  peritoneum.  Without  doubt  many 
of  these  affections  may  be  due  to  other  germs  than  the  gonococcus,  such  com- 
plications representing  a  form  of  mixed  infection. 

URETHRITIS 

The  urethra  is  nearly  always  involved  in  gonorrhoeal  infection,  and  the 
presence  of  inflammation  in  this  canal  is  in  itself  presumptive  evidence  of  the 
nature  of  the  infection. 

Acute  Urethritis. — The  acute  stage  of  the  disease  is  brief,  and  is  ac- 
companied by  symptoms  of  moderate  severity  as  compared  with  urethritis 
in  the  male.  It  is  less  liable  to  become  chronic  than  is  the  case  in  men,  or 
if  it  lingers  it  causes  symptoms  so  slight  that  they  are  readily  overlooked; 
hence  the  frequency  of  the  involvement  of  the  urethra  in  gonorrhoeal  inflamma- 
tion is  often  underestimated. 

Symptoms. — These  are  very  much  like  those  observed  in  men.  The  incu- 
bation period  varies  from  a  few  hours  to  five  or  six  days,  and  exceptionally 


GONORRHCEA  IN  WOMEN  AND  CHILDREN  217 

is  much  longer.  Slight  tickling  or  burning  sensations  on  urination,  moderate 
purulent  discharge,  demonstrated  by  milking  the  urethra  from  above  down- 
ward, and  a  swollen,  (edematous  urethral  orifice  are  often  the  only  symptoms 
which  can  be  detected,  though  in  specially  sensitive  women  there  will  be  at 
the  beginning  of  the  attack  rigors,  slight  fever,  and  general  malaise.  In 
from  a  few  days  to  two  or  three  weeks  even  these  symptoms  disappear,  and  the 
disease  is  regarded  as  cured. 

Finger  believes,  however,  that  it  becomes  chronic  in  women  much  more 
frequently  than  is  the  case  in  men,  being  subject  to  exacerbations,  and  often 
months  after  the  original  attack  exciting  a  urethrocystitis,  the  symptoms  and 
course  of  which  are  much  like  those  of  the  same  condition  in  man,  except  that 
it  is  less  severe  and  more  amenable  to  treatment. 

Chronic  urethritis  rarely  excites  sufficiently  characteristic  symptoms  to 
suggest  a  probable  diagnosis  without  a  thorough  examination.  This  should 
be  conducted  at  a  time  when  the  patient  has  not  urinated  for  several  hours. 
Pressure  on  the  urethra  from  behind  forward  may  show  that  this  tube  is 
thickened  and  somewhat  sensitive,  and  will  usually  press  out  a  thin,  milky, 
mucopurulent  drop.  In  case  there  is  not  sufficient  discharge  for  this,  the 
vulva  and  vagina  are  carefully  washed  and  the  patient  is  requested  to  urinate 
in  two  portions.  Clap-shreds  and  pus  will  be  found  in  the  first  portion; 
if  pus  is  discovered  in  the  last  portion,  this  is  usually  indicative  of  the  pres- 
ence of  chronic  cystitis. 

An  endoscopic  examination  in  cases  of  acute  urethritis  in  women  shows 
redness,  swelling,  and  general  acute  congestion  of  the  mucous  membrane.  In 
the  chronic  cases  diffuse  redness,  areas  of  epithelial  thickening,  and  some- 
times comparatively  deep  erosions  are  observed,  the  latter  especially  about 
the  openings  of  follicles. 

Folliculitis. — As  in  the  male,  the  urethra  contains  many  follicles,  and 
these  are  subject  to  gonorrhoeal  inflammation,  forming  small  tender  tumors 
which  commonly  evacuate  their  contents  into  the  urethra. 

There  are  two  follicles,  known  as  Skene's  tubules,  which  are  particularly 
liable  to  become  infected.  These  are  situated  in  the  lower  urethral  wall  and 
open  just  within  the  external  urethral  orifice.  A  fine  probe  can  be  inserted 
into  the  duct  of  each  to  a  depth  of  from  one-half  to  three-fourths  of  an  inch. 
When  these  follicles  are  acutely  inflamed  and  their  urethral  openings  firmly 
blocked,  the  softening  and  breaking  down  may  cause  urethrovestibular  or 
urethrovaginal  fistulae. 

In  addition  to  these  two  deep  follicles,  there  are  a  number  of  smaller  ones 
situated  about  the  meatus.  Many  or  all  of  these  may  become  inflamed,  render- 
ing the  urethral  opening  unsymmetrical.  They  often  rupture  into  the  urethra, 
but  again  fill  up  and  continue  to  discharge  intermittently. 

The  frequency  with  which  these  follicles  are  involved  in  gonorrhoeal  in- 
flammation makes  their  recognition  particularly  important.  A  careful  exami- 
nation usually  shows  at  once  the  true  nature  of  the  case,  since  immediately 
after  the  urethra  has  been  washed  clean  by  the  act  of  urination  pressure 
causes  exudation  of  pus.  Moreover,  on  direct  examination  the  inflamed  open- 
ings of  the  follicles  can  generally  be  found. 


218  GEXITO-URIXARY  SURGERY 

Diagnosis, — The  diagnosis  of  acute  urethritis  is  dependent  upon  the  symp- 
toms and  on  finding  the  gonococcus. 

If  after  holding  the  water  for  several  hours  no  pus  can  be  milked  from  the 
urethra,  the  \nalva  and  vagina  should  be  washed  free  of  discharge.  The  patient 
should  then  micturate,  and  the  urine  should  be  carefully  examined  for  pus. 

Prognosis. — The  prognosis  of  urethritis  in  women  is  much  more  favorable 
than  in  men.  The  disease  lasts  for  but  a  short  time;  the  chronic  forms  of  it 
occasion  no  trouble  and  usually  undergo  spontaneous  cure  without  producing 
serious  or  permanent  alterations  in  the  urethral  mucous  membrane. 

Treatment. — The  treatment  of  acute  urethritis  in  women  is  conducted  on 
the  same  principles  as  govern  the  management  of  this  disease  in  men.  The 
diet  is  regulated,  and  the  urine  is  rendered  unirritating  by  the  administration 
of  potassium  citrate  or  sodium  bicarbonate  and  an  abundance  of  water. 

Balsams  may  be  given  from  the  first,  and  as  soon  as  the  acute  symptoms 
subside  injections  are  employed.  These  should  be  driven  in  by  the  ordinary 
clap  syringe,  but  not  more  than  half  a  drachm  should  be  injected  at  one  time. 
The  solutions  employed  are  those  used  in  the  male  urethra,  but  may  be  slightly 
stronger.  As  soon  as  the  acute  stage  is  past  the  lesions  are  located  by  the 
urethroscope,  and  are  treated  directly  by  means  of  iodine  two  to  ten  per  cent. 


Fig.  114. — Short  straight  boiigie. 

solution  in  glycerin,  or  silver  nitrate  one  to  ten  per  cent.,  these  drugs  of  course, 
being  applied  only  to  the  inflamed  spots  by  means  of  cotton  tampons. 

Chronic  urethritis  in  women  is  usually  dependent  upon  follicuHtis,  either  the 
paraurethral  glands  about  the  meatus  or  a  group  of  follicles  near  the  neck  of  the 
bladder  being  involved.  Destruction  of  the  follicles  by  a  finely  pointed  stick 
of  silver  nitrate  or  the  electric  needle  when  they  are  accessible,  or  when  the 
inflammation  is  placed  near  the  bladder,  the  use  of  the  endoscope  for  the  appli- 
tion  of  iodine  or  silver  nitrate,  is  indicated  in  these  cases. 

Exceptionally  true  stricture  forms,  usually  at  or  near  the  meatus.  The 
sj^mptoms  are  frequent  micturition,  slight  dribbling,  and  gleet,  though  the  latter 
is  rare!}'  noticed.  The  fact  that  stricture  may  result  from  gonorrhoeal  inflam- 
mation of  the  female  urethra  would  suggest  a  search  for  this  condition  in  cases 
of  functional  urinary  difficulty  in  women.  The  diagnosis  is  readily  made  by 
means  of  the  bulbous  bougie.  Narrowing  at  or  very  near  the  meatus  may 
require  division,  the  knife  cutting  backward.  Gradual  dilatation  will  prove 
efficient  for  all  other  cases  not  traumatic.  Straight  metal  bougies  are  employed 
running  up  to  40  F.  (Fig.  114). 

There  is  one  form  of  chronic  urethritis  much  resembling  in  symptoms  the 
posterior  urethritis  observed  in  men.  The  patient  complains  of  frequent  urgent 
urination,  tenesmus,  and  reflexes,  such  as  vaginismus  and  backache,  and  a 
general  conditioii  of  neurasthenia.     On  urethroscopic  examination  the  mucous 


GOXORRHCEA  IN  WOMEN  AND  CHILDREN  219 

membrane   at  the  neck  of   the  bladder — i.e.,  within   the   grip   of   the  vesical 
sphincter — is  found  greatly  thickened  and  congested  or  even  fissured. 

The  treatment  consists  in  wide  dilatation  (40  to  SOF.)  and  the  application 
of  strong  solutions  of  silver  nitrate. 

VULVITIS 

Inflammation  of  the  vulva  is  characterized  by  oedematous  swelling,  redness, 
and  erosions  affecting  the  greater  and  the  lesser  lips,  and  by  a  profuse  purulent, 
irritating,  extremely  fetid  discharge.  This  discharge  coming  in  contact  with  the 
neighboring  skin  produces  a  dermatitis,  which  may  pass  backward  towards  the 
anus  or  downward  along  the  inner  surfaces  of  the  thighs.  There  are  constant 
itching  and  burning  about  the  vulva,  which  become  aggravated  to  severe  pain 
by  walking  or  motion  of  any  kind  involving  the  lower  half  of  the  body.  Trick- 
ling of  the  urine  over  the  abraded  surfaces  occasions  much  burning.  Involve- 
ment of  the  inguinal  glands  is  by  no  means  uncommon. 

Usually  vulvitis  has  a  tendency  to  spontaneous  recovery.  Occasionally, 
especially  in  children,  it  becomes  chronic,  persisting  in  the  vestibular  glands, 
and  not  only  in  those  about  the  urethra,  but  also  in  those  placed  at  the  inner 
surface  of  the  lesser  lips.  These  chronically  inflamed  glands  cause  practically 
no  symptoms,  and  are  detected  only  by  direct  examination.  Hyperaemic  or 
eroded  spots  may  be  found  overlying  the  swollen  glands,  which  can  sometimes 
be  felt  as  small  nodules;  condylomata  are  frequently  observed. 

Treatment. — Cleanliness  will  usually  accomplish  cure,  which  is  hastened 
by  the  employment  of  antiseptic  and  astringent  lotions  and  by  protecting 
inflamed  surfaces  from  contact  .with  the  urine.  In  the  acute  stages  the  treat- 
ment consists  in  irrigation  with  very  hot  saline  solution  containing  1  to  6000 
bichloride  of  mercury,  practised  twice  a  day,  or  more  frequently  if  the  discharge 
is  free.  Each  irrigation  is  followed  by  the  insertion  between  the  greater  and 
the  lesser  lip  on  each  side  of  a  thin  sheet  of  cotton  dipped  in  dilute  lead  water. 
This  cotton  should  be  changed  every  two  or  three  hours.  As  the  symptoms 
subside  the  inflamed  parts  should  be  painted  once  daily  with  a  one  per  cent, 
solution  of  silver  nitrate,  and  the  irrigation  should  be  followed  by  the  use  of 
an  astringent  dusting  powder  and  dry  cotton. 

BARTHOLINITIS 

Inflammation  of  Bartholin's  glands  is  perhaps  the  most  frequent  complication 
of  vulvitis,  though  even  this  is  exceptional.  It  may  be  either  acute  or  chronic. 
Whether  it  be  due  to  infection  of  these  glands  by  gonococci  or  by  the  ordinary 
pus  microbes,  the  clinical  fact  remains  that  it  is  so  rarely  associated  with  non- 
gonorrhceal  forms  of  vulvitis  that  if  it  occurs  it  is  almost  pathognomonic  of 
gonorrhoea. 

Acute  Bartholinitis. — Acute  inflammation  of  these  glands  develops  sud- 
denly, either  during  the  fulminant  stage  of  acute  clap  or  long  afterwards,  from 
lighting  up  of  the  chronic  inflammation  by  sexual  excess  or  other  cause. 

There  appears  in  the  posterior  third  of  the  greater  lip,  usually  on  one  side 
alone,  though  sometimes  on  each  side,  a  tender,  hard,  very  clearly  outlined 
tumor  about  the  size  of  a  hazel-nut.    This  is  soon  followed  by  an  oedematous 


220  GENITO-URINARY  SURGERY 

swelling  of  the  greater  lip,  sometimes  extending  to  the  lesser  lip,  and  often  as 
far  forward  as  the  prepuce  of  the  clitoris.  In  place  of  a  distinctly  outlined  tumor 
there  develops  a  dense  inflammatory  infiltration,  forming  an  extremely  tender, 
painful  swelling,  often  as  large  as  a  pigeon's  egg,  the  surface  of  which  is  red. 
Shortly  fluctuation  is  detected,  suppuration  being  denoted  at  the  same  time  by 
the  constitutional  symptoms  of  pus-formation. 

The  pus  may  break  through  the  capsule  of  the  gland,  the  overlying  skin 
remaining  intact.  In  this  case  it  is  apt  to  burrow  backward  along  the  perineum, 
forming  extensive  sinuses,  and  even  opening  into  the  rectum.  Usually  the  skin 
also  ulcerates  and  the  pus  is  evacuated  on  the  inner  surface  of  the  greater  lip. 
This  pus  is  blood-stained  and  foul-smelling. 

Chronic  Bartholinitis. — Chronic  inflammation  of  Bartholin's  glands  may 
appear  as  an  inflammation  of  the  gland-ducts  alone,  the  most  frequent  form, 
or  may  involve  the  gland  substance.  In  the  latter  case  hard  nodules  are  felt 
on  palpation,  and  on  pressure  a  purulent  fluid  containing  gonococci  can  be 
forced  from  the  ducts.  When  the  ducts  alone  are  infected  no  induration  will  be 
felt  on  palpation,  and  on  inspection  nothing  in  seen  except  an  area  of  hypersemic, 
or  possibly  eroded,  mucous  membrane  around  the  duct  opening.  Pressure  may 
cause  a  small  drop  of  purulent  fluid  to  exude.  Sometimes  a  large  quantity  of 
this  fluid  can  be  squeezed  out,  owing  to  retention  from  blocking  of  the  duct. 
Not  infrequently  this  duct  is  the  only  mucous  surface  in  which  the  gonococci 
still  survive:  hence  in  an  examination  to  confirm  the  presence  or  the  absence 
of  gonorrhcea  the  condition  of  Bartholin's  glands  and  their  ducts  must  always  be 
most  carefully  investigated. 

Treatment. — The  treatment  of  the  acute  inflammation  in  the  early  stages 
before  there  is  pus-formation  consists  in  putting  the  patient  to  bed,  keeping 
the  bowels  open,  and  applying  evaporating  lotions,  constantly  renewed.  Of 
these,  lead  water  and  dilute  alcohol  are  perhaps  the  best.  As  soon  as  fluctuation 
is  detected,  or  when  the  constitutional  symptoms  denote  pus-formation,  the  pus 
should  be  evacuated  by  a  free  incision  made  on  the  inner  surface  of  the  greater 
lip.  The  cavity  should  be  curetted,  washed  with  1  to  1000  bichloride  solution, 
and  packed  with  iodoform  gauze.  This  packing  must  be  repeated  frequently, 
and  the  cavity  must  be  made  to  heal  from  the  bottom. 

Chronic  inflammation  is  extremely  difficult  to  cure.  When  the  gland  is 
involved  and  appears  as  a  hard,  slightly  tender,  circumscribed  tumor  subject 
to  occasional  attacks  of  subacute  inflammation,  the  whole  gland  should  be 
dissected  out.  If  the  ducts  alone  are  involved,  the  catarrhal  process  may  be 
cured  by  astringent  and  antiseptic  injections  carried  in  by  means  of  a  h3^o- 
dermic  needle  blunted  at  the  end.  Usually,  however,  it  will  be  necessary  to  split 
the  duct  thoroughly,  scrape  it,  and  pack  with  iodoform  gauze  until  healing 
takes  place. 

METRITIS 

Acute  metritis  develops  in  the  course  of  acute   urethritis,   vulvitis,   or 

vaginitis.     It  is  characterized  by  rigors  and  fever,  pain  in  the  hypogastric  and 

sacral  regions,  generally  aggravated  by  motion,  and  a  discharge  from  the  cervix, 

at  first  muco-purulent,  then  frankly  purulent.     On  examination  the  womb  is 


GONORRHCEA  IN  WOMEN  AND  CHILDREN  221 

found  to  be  tender  and  enlarged,  and  the  cervix  is  swollen,  oedematous,  and 
often  eroded. 

The  inflammation  may  be  limited  to  the  cervical  mucous  membrane.  More 
commonly  it  involves  the  entire  endometrium,  and  it  may  extend  to  the  peri- 
metrium, tubes,  ovaries,  and  peritoneum. 

Diagnosis. — The  diagnosis  is  founded  on  the  coexistence  of  urethritis, 
bartholinitis,  etc.,  and  on  the  discovery  of  the  gonococcus. 

Prognosis. — The  prognosis  as  to  complete  cure  must  be  guarded,  since  the 
disease  has  a  tendency  after  subsidence  of  acute  symptoms  to  linger  indefinitely. 

Chronic  metritis,  according  to  Finger,  is  acquired  from  the  discharges  of 
a  chronic  gonorrhoea  of  the  urethra  or  external  genitalia  of  the  woman,  the 
uterus  having  escaped  during  the  acute  stage  of  the  disease,  or  is  implanted 
by  a  male  suffering  from  gleet.  This  form  of  metritis  is  the  one  commonly 
observed  in  young  married  women  infected   by   their  husbands. 

Symptoms. — The  inflammation  is  ushered  in  by  a  mucopurulent  discharge, 
which  excites  little  attention,  since  it  is  attributed  to  cold,  defloration,  excess, 
or  other  apparently  sufficient  cause.  The  discharge  becomes  profuse  at  times, 
and  is  especially  free  after  the  menstrual  period.  Gradually  menstruation  becomes 
painful  and  irregular  and  the  flow  is  scanty;  at  the  same  time  there  is  a  deteri- 
oration in  general  health,  with  a  sense  of  weight  and  dragging  about  the  uterus, 
and  the  patient  becomes  neurotic  and  unfit  for  work. 

The  course  of  the  chronic  inflammation  is  varied  by  intercurrent  subacute 
attacks,  somewhat  simulating  acute  metritis. 

On  examination  a  swollen,  tender  uterus  is  found,  from  which  is  discharged 
mucopus.    The  gonococci  can  rardy  be  discovered  in  this  discharge. 

Diagnosis. — The  diagnosis  of  chronic  gonorrhoeal  metritis  is  extremely 
difficult.  A  preceding  history  of  acute  gonorrhoea,  a  venereal  record  on  the 
part  of  the  husband,  or  infection  of  others  by  the  discharges,  would  strongly 
suggest  the  causative  agency  of  the  gonococcus  in  producing  this  inflammation. 

Prognosis. — This  form  of  inflammation  has  little  tendency  towards  spon- 
taneous cure;  rather  it  extends  slowly,  particularly  in  the  direction  of  the  tubes 
and  ovaries,  producing  sterility  and  chronic  invalidism,  and  in  many  cases 
ultimately  destroying  life. 

GONORRHCEAL  SALPINGITIS  AND  OOPHORITIS 
These  are  caused  by  an  extension  of  the  gonorrhoeal  inflammation  to  the 
tubes  and  ovaries,  and  are  not  characterized  by  any  pathognomonic  symptoms. 
Menstruation  is  usually  irregular,  profuse,  and  very  painful,  intercurrent  attacks 
of  pelvic  peritonitis  occur,  and  there  is  often  a  rapid  loss  of  health.  All  these 
symptoms  are  also  observed  in  endometritis. 

The  tubes  may  be  filled  with  pus,  and  this  pus  may  escape  into  the  uterus 
or  may  make  a  way  for  itself  into  the  bowel,  the  case  thus  recovering  spontane- 
ously, or  it  may  ulcerate  through  the  tube  or  escape  by  its  fimbriated  extremity 
and  occasion  a  fulminant  form  of  peritonitis. 

With  involvement  and  obliteration  of  the  tubes  the  ovaries  are  nearly 
always  diseased,  first  a  parovaritis  developing,  followed  by  atrophy  and  cyst- 
formation  of  the  ovary. 


222  GENITO-URINARY  SURGERY 

Diagnosis. — The  diagnosis  of  gonorrhoea!  salpingitis  and  ovaritis  must  be 
founded  on  bimanual  examination,  preferably  with  the  patient  well  relaxed 
by  ether. 

PERIMETRITIS 

The  acute  form  of  perimetritis  is  most  prone  to  develop  during  pregnancy 
or  after  childbirth.  The  symptoms  are  those  of  acute  pelvic  peritonitis  and 
septic  absorption, — i.e.,  pain,  tenderness,  vomiting,  and  fever, — and  may  ter- 
minate fatally  in  a  few  days.  More  commonly  resolution  takes  place,  even 
though  there  is  apparently  a  large  exudate.  This  Sanger  considers  typical  of 
gonorrhceal  infection. 

The  recurring  form  of  perimetritis  is  due  to  pus-tubes;  the  symptoms  are 
those  of  acute  local  peritonitis,  and  are  most  severe  and  lasting  during  the 
first  attack.     In  the  intervals  the  woman  may  enjoy  perfect  health. 

The  chronic  form  is  characterized  by  persistent  pain  and  tenderness.  Every 
strain  or  jar  is  unbearable,  coitus  is  not  possible,  and  there  is  usually  a  marked 
condition  of  neurasthenia. 

Treatment. — Gonorrhoeal  cervical  endometritis  should  be  treated  first  by 
thoroughly  cleansing  the  vagina  with  antiseptic  douches,  1  to  2000  bichloride 
(hot).  The  cervix  is  then  exposed  and  its  endometrium  cleared  of  the  viscid 
mucus  which  coats  its  surface  by  means  of  cotton  tampons.  Finally,  the  whole 
diseased  surface  is  touched  with  one  of  the  following  solutions,  named  in  the 
order  of  their  efficiency:  1,  silver  nitrate  ten  per  cent.;  2,  tincture  of  iodine; 
3,  copper  sulphate  ten  per  cent. 

Small  cysts  found  in  this  form  of  inflammation  should  be  punctured,  and 
when  there  is  marked  congestion  local  depletion  is  indicated,  the  cervix  being 
scarified  by  means  of  a  long-handled  knife. 

When  the  inflammation  resists  these  milder  forms  of  treatment,  a  thorough 
curetting,  followed  by  the  application  of  zinc  chloride,  twenty  per  cent,  solution, 
and  by  packing  with  iodoform  gauze,  will  be  indicated. 

Endometritis  involving  the  body  of  the  womb  should  receive  no  direct  treat- 
ment during  the  acute  stage.  Rest  in  bed,  hot  vaginal  douches,  free  action  on 
the  bowels  by  salines,  and,  when  pain  is  very  intense,  the  administration  of 
an  anodyne,  represent  the  safest  and  most  efficient  treatment  in  this  stage. 
Even  when  the  disease  has  become  chronic  it  is  safer  not  to  perform  intra- 
uterine applications  in  the  office.  The  general  health  should  receive  attention; 
the  activity  of  the  patient  should  be  limited,  especially  just  before,  during,  and 
immediately  after  the  menses.  Hot  douches  are  of  advantage  in  this  condition 
also,  as  are  local  applications  to  diseased  conditions  in  the  cervix,  and  tampons 
moistened  with  glycerite  of  boroglycerin,  ichthyol,  etc.  If  these  measures  fail 
to  produce  a  cure,  in  the  absence  of  disease  of  the  adnexa  the  cervix  should  be 
dilated  and  the  uterus  thoroughly  curetted  and  treated  with  tincture  of  iodine, 
general  anaesthesia  being  employed.  When  the  disease  has  extended  to  the 
parametrium,  tubes,  ovaries,  and  pelvic  peritoneum,  causing  the  local  and 
general  symptoms  of  acute  pelvic  peritonitis,  free  movements  of  the  bowels, 
prolonged  hot  baths,  and  hot  vaginal  douches  are  indicated  until  the  acute 
stage  has  passed  and  very  definite  localizing  symptoms  point  to  the  use  of  the 
knife. 


GONORRHCEA  IN  WOMEN  AND  CHILDREN  223 

VAGINITIS  .  ■ 

Inflammation  of  the  vagina,  at  one  time  regarded  as  the  most  characteristic 
manifestation  of  gonorrhoea  in  the  female,  is  now  recognized  as  occurring  much 
less  frequently  than  urethritis  or  endometritis.  The  many  layers  of  squamous 
epithelium  are  usually  sufficient  to  prevent  penetration  of  the  gonococci.  When, 
however,  the  vaginal  mucous  membrane  is  succulent  and  the  spaces  between 
the  epithelial  cells  are  widened,  as  in  infants  and  children,  or  in  young  virgins, 
the  gonococci  may  penetrate  deeply  and  produce  a  true  vaginitis.  The  vaginal 
inflammation  sometimes  noted  in  older  women  is  often  due  to  the  irritating 
effect  of  decomposing  discharges  which  flow  from  the  endometrium. 

Symptoms. — A  sense  of  weight  and  burning  in  the  vagina,  aggravated  by 
motion,  a  free  purulent  discharge,  and  slight  fever  and  malaise  are  the  only 
symptoms  of  which  the  patient  complains.  An  examination  shows  the  vaginal 
mucous  membrane  reddened,  oedematous,  and  freely  suppurating,  and  its  walls 
somewhat  stiffened  by  recent  inflammatory  exudation.  The  epithelium  is  eroded 
in  places,  and  there  are  observed  extensive  granular  patches,  especially  in  preg- 
nant women.  Often  there  is  so  much  tenderness  that  examination  either  by 
the  finger  or  by  the  speculum  is  impossible. 

Diagnosis. — This  is  founded  on  ocular  and  digital  examination  showing 
an  acute  inflammation  of  the  vagina,  usually  associated  with  urethritis  and 
vulvitis,  and  often  with  endometritis.     The  gonococcus  may  be  found. 

Prognosis. — In  itself  gonorrhoeal  vaginitis  is  not  a  serious  affection.  It  is 
usually  cured  in  two  or  three  weeks.  Exceptionally  it  becomes  chronic,  and  in 
prostitutes  causes  a  stiffened,  dry,  rough  condition  of  the  mucous  membrane, 
termed  xerosis  vaginae. 

Treatment. — This  should  be  cleansing  and  antiseptic.  Twice  a  day  the 
vagina  is  flushed  out  with  two  quarts  of  normal  saline  solution  (nine-teiiths 
per  cent.)  containing  1  to  4000  corrosive  sublimate.  This  douche  is  best  given 
from  a  fountain  syringe  raised  two  to  four  feet.  During  its  administration  the 
patient  should  lie  on  her  back,  with  the  hips  slightly  elevated,  or,  better  still, 
should  assume  the  knee-elbow  position.  When  there^  is  a  bath-tub  these  flush- 
ings are  easily  managed. 

When  the  acute  symptoms  have  subsided,  a  speculum  is  introduced,  and 
the  inflarned  and  granular  patches,  or  the  entire  vagina  if  all  its  surface  is 
involved,  are  painted  with  ten  per  cent,  silver  nitrate  solution.  This  is  repeated 
in  three  days  if  necessary.  Tincture  of  iodine  may  be  used  in  place  of  the  silver 
nitrate.  In  cases  seen  early,  or  where  the  inflammation  is  not  so  acute  that 
insertion  of  a  speculum  is  very  painful,  the  silver  nitrate  painting  is  indicated 
from  the  first. 

In  chronic  cases,  irrigation,  followed  by  paintings  of  the  vagina  with  strong 
solutions  of  silver  or  copper  ten  per  cent.,  or  iodine  tincture,  and  then  by  tam- 
poning with  iodoform  gauze,  is  repeated  daily  for  from  five  to  seven  days;  then 
dilute  antiseptic  washes  are  employed  once  daily  for  two  weeks  till  epithehal 
regeneration  is  completed.  Suppositories  of  tannin  and  boric  acid  (teji  grains 
of  each)  inserted  twice  daily  will  greatly  lessen  the  discharge,  and  will  some- 
times cure  a  chronic'  inflammation  when  other  means  have  failed. 


224  GENITO-URINARY  SURGERY 

THE  QUESTION  OF  CURE 
In  women  the  detection  of  the  gonococcus  when  these  organisms  are  present 
in  small  numbers  is  much  more  difficult  than  in  men,  on  account  of  anatomical 
differences.  Ihe  regions  which  should  be  specially  examined  are  the  urethra, 
including  Skene's  tubules,  Bartholin's  glands,  and  the  cervix  uteri.  Repeated 
examinations  of  the  discharge  or  secretions  from  these  points  should  be  made, 
the  most  favorable  time  being  immediately  before  or  at  the  conclusion  of  the 
menses.  Alcoholic  indulgence  also  increases  the  likelihood  of  finding  gonococci ; 
application  of  the  glycerite  of  boroglycerin  to  the  cervix  by  means  of  a  tampon 
inserted  the  day  before  the  examination  is  to  be  made  is  often  of  advantage  on 
account  of  the  mild  reaction  excited. 

In  coming  to  a  decision  as  to  the  health  of  such  a  patient  one  must  always 
take  into  consideration  the  length  of  time  which  has  elapsed  since  infection, 
and  the  point  to  which  the  infection  apparently  travelled,  a  careful  bimanual 
pelvic  examination  being  made  to  ascertain  the  present  condition  of  the  tubes 
and  ovaries.  The  probability  of  cure,  that  is  of  freedom  from  gonococci,  is 
directly  proportionate  to  the  time  which  has  elapsed  since  infection,  and  in- 
versely proportionate  to  the  extent  to  which  the  disease  became  disseminated. 

In  deciding  the  question  of  the  marriageability  of  a  woman  who  has  had 
gonorrhoea  one  must  consider  the  possible  structural  changes  which  may  have 
taken  place  in  the  tubes,  and  which  may  render  the  patient  sterile  or  liable  to 
extra-uterine  pregnancy,  as  well  as  the  actual  presence  of  gonococci  in  her 
secretions. 

In  women  even  more  than  in  men  is  the  gonococcus  fixation  test  a  valuable 
means  of  determining  when  a  patient  may  be  considered  well.  It  is  almost 
always  positive  when  the  uterus  or  adnexa  is  infected. 

GONORRHCEA   IN    CHILDREN 

Male  Children. — The  course  of  gonorrhoea  as  observed  in  maie  children 
is  not  markedly  different  in  symptomatology,  duration,  or  treatment  from 
the  disease  as  it  occurs  in  adults.  It  is  a  rare  disease,  at  least  in  boys  under 
twelve  years  of  age,  in  this  respect  affording  a  marked  contrast  to  gonorrhoeal 
vulvovaginitis  observed  in  the  opposite  sex.  The  cause  is  usually  an  attempt 
at  intercourse,  often  suggested  by  a  much  older  female.  Very  exceptionally 
the  contagion  may  be  mediate  by  means  of  fabrics  or  by  foreign  bodies  previ- 
ously infected  being  introduced  within  the  urethra.  When  the  disease  develops 
in  boys  over  twelve  years  of  age  it  is  usually  acquired  in  the  ordinary  manner. 

Symptoms. — These  are  the  same  as  have  been  already  described.  They 
develop  more  quickly  after  exposure  to  contagion,  and  run  a  somewhat  more 
acute  course  than  is  customary  in  the  adult,  the  whole  penis  usually  being 
swollen,  the  discharge  being  profuse,  and  the  child  complaining  bitterly  of  the 
pain  incident  to  micturition  and  erection. 

Complications. — Of  these  the  most  frequent  is  balanoposthitis^  incident, 
no  doubt,  to  the  phimosis  usually  present  in  children  and  to  the  vulnerability 
of  the  mucous  coverings  of  the  glans  and  foreskin.  Indeed,  other  complica- 
tions are  rare,  though  a  number  of  well-authenticated  instances  of  epididymitis 


GONORRHGEA  IN  WOMEN  AND  CHILDREN  225 

are  reported.  Hyperacute  posterior  urethritis  and  urethrocystitis  are  by  no 
means  exceptional.    There  is  usually  pronounced  fever. 

Diagnosis. — This  is  founded  on  the  presence  of  the  gonococcus.  The 
search  for  the  gonococcus  should  always  be  made,  since  simple  irritative 
urethritis  is  by  no  means  uncommon  in  children,  and  is  in  the  beginning  of  its 
course  not  to  be  distinguished  clinically  from  true  gonorrhoea.  This  simple 
urethritis  is  often  excited  by  the  introduction  of  foreign  bodies,  by  a  simple 
balanoposthitis,  and  by  the  irritation  incident  to  the  passage  of  highly  con- 
densed urine. 

It  is  usually  mild  and  of  short  duration,  contrasting  with  the  inflammation 
resulting  from  the  presence  of  the  gonococcus. 

The  prognosis  is  favorable,  the  discharge  usually  ceasing  in  from  three  to 
six  weeks.  In  weak,  strumous,  cachectic  children  it  is  liable  to  last  much  longer 
and  may  run  into  gleet.    Stricture  has  been  observed  as  a  sequel. 

Treatment. — This  consists  in  rest  in  bed,  the  relief  of  phimosis  by  opera- 
tion, circumcision  being  performed  if  the  parts  are  not  too  greatly  swollen, 
light  diet,  hot  baths,  the  administration  of  laxatives  when  required,  and  medi- 
cines calculated  to  subdue  the  fever,  render  the  urine  bland  and  slightly  anti- 
septic, and  control  the  painful  erections.  These  indications  should  be  met  by 
aconite  in  small  doses,  boric  acid,  and  potassium  bromide.  An  excellent  formula 
for  a  child  of  five  years  is  the  following: 

^  . 

Potassii    bromidi    3ss  to  i 

Acidi  borici gr.  xlviii 

Tinct.    aconiti    gtt.  xii 

Tinct.    belladonnse     gtt.  xxiv 

Spts.  a;theris  nit fSiii 

Liq.  potassii  citratis    , q.  s.  ad  fSvi 

M.  S.     Dessertspoonful  in  water  every  two  hours. 

The  penis  should  be  kept  wrapped  in  cloths  wet  in  lead  water  and  dilute 
alcohol. 

On  the  subsidence  of  the  acute  inflammatory  symptoms  injections  may  be 
administered.  These  should  contain  the  remedies  used  in  similar  conditions 
of  the  adult,  but  should  be  somewhat  weaker,  varying  from  one-half  to  two- 
thirds  strength,  according  to  the  age  of  the  child.  They  should  never  be  used 
strong  enough  to  cause  acute  or  prolonged  pain. 

The  injections  should  be  administered  immediately  after  the  child  urinates, 
from  half  a  drachm  to  a  drachm  being  thrown  in  each  time.  As  soon  as  the  fever 
subsides  the  internal  administration  of  salol  is  serviceable.  This  may  be  given 
in  doses  of  one  to  three  grains  six  times  a  day,  depending  upon  the  age  of 
the  patient,  and  may  be  combined  with  balsam  of  copaiba  or  oil  of  sandal 
wood  in  appropriate  doses.  When  the  fever  persists  and  assumes  an  irregular 
intermittent  type  full  doses  of  quinine  night  and  morning  will  be  found  ser- 
viceable. 

Female    Children. — In    female    children   gonorrhoea    takes    the    form    of 
urethro-vulvovaginitis.    It  is  different  from  the  disease  as  it  appears  in  the  adult, 
since  in  the  latter  the  vagina  is  only  exceptionally  involved.    The  catarrhal  or 
irritative  form  must  be  distinguished  from  that  due  to  the  gonococcus. 
15 


226  GENITO-URINARY  SURGERY 

Catarrhal  vulvovaginitis  may  be  caused  by  any  irritant,  such  as  pro- 
longed contact  of  irritating  urine  or  of  faeces,  lack  of  cleanliness,  seat-worms, 
decomposing  discharges  incident  to  exanthemata,  etc.  The  inflammation  is 
usually  confined  to  the  vulva,  the  vagina  being  but  slightly  involved,  and  the 
urethra  escaping  entirely. 

The  symptoms  are  those  of  ordinary  inflammation,  as  heat,  redness,  swelling, 
pain,  or  itching,  increased  by  contact  with  urine.  There  are  often  extensive 
excoriations,  or  even  distinct  ulcers. 

The  diagnosis  is  founded  on  the  absence  of  gonococci  and  on  the  presence 
of  vast  numbers  and  varieties  of  other  microorganisms,  the  comparatively  mild 
course  of  the  affection,  though  it,  may  be  extremely  chronic  and  rebellious  to 
treatment,  and  the  absence  of  involvement  of  the  urethra  and  vagina.  The 
prognosis  is  good. 

The  treatment  consists  in  removal  of  the  cause  and  in  strict  local  cleanliness. 
Since  this  affection  is  very  commonly  associated  with  seat-worms,  these  should 
always  be  searched  for.  Mild  antiseptic  washes,  as  boric  acid,  followed  by 
dusting  powders,  such  as  finely  powdered  bismuth  or  zinc  oxide,  and  the  appli- 
cation of  a  thin  layer  of  cotton  between  abraded  and  inflamed  surfaces, — i.e,^ 
between  the  greater  and  the  lesser  lip  of  each  side, — usually  result  in  cure. 
WTien  the  disease  becomes  chronic,  stronger  astringent  injections  and  washes 
are  required. 

Gonorrhoeal  Vulvovaginitis. — This  is  an  affection  which  recent  studies 
have  shown  to  be  much  more  prevalent .  and  serious  in  its  ultimate  effects  than 
has  generally  been  believed. 

Cause. — In  the  new-born  and  in  young  infants  gonorrhoeal  vulvovaginitis  is 
acquired  from  the  mother,  either  from  direct  contagion  during  parturition,  or 
more  mediate  contagion  later  through  the  agency  of  towels,  wash-rags,  fingers, 
etc.  When  it  develops  after  the  nursing  period  it  is  usually  due  to  mediate 
contagion.  Thus,  it  has  been  shown  that  when  one  case  is  introduced  into 
an  institution  the  disease  spreads  rapidly,  probably  by  the  medium  of  the  bath, 
or  towels.  The  genital  mucous  membrane  of  the  child  seems  to  be  exceedingly 
sensitive  to  the  gonococcus.  Exceptionally  vulvovaginitis  is  caused  by  criminal 
practices.  When  these  are  suspected,  and  consequently  when  there  is  a  possi- 
bility of  a  medicolegal  contest,  the  presence  of  the  gonococcus  should  always 
be  confirmed  by  culture  on  artificial  media. 

Symptoms. — These  are  pronounced.  The  discharge  is  free,  purulent,  often 
blood-stained.  It  comes  from  the  urethra,  vagina,  and  vulva.  There  are  great 
swelling,  intense  hypersemia  of  the  mucous  surfaces,  which  bleed  readily  when 
touched,  pronounced  ardor  urinae,  and  marked  and  persistent  fever.  There  is 
often  bitter  complaint  of  severe  abdominal  and  pelvic  pain.  On  rectal  examina- 
tion the  womb  may  be  found  tender  and  swollen. 

The  diagnosis  is  founded  on  the  presence  of  gonococci,  the  involvement  of 
the  urethra,  and  the  severity  of  the  symptoms. 

The  prognosis  is  good.  None  the  less,  cases  of  peritonitis  and  death  have. 
been  reported,  and  on  the  basis  of  apparently  clear  clinical  records  it  has  been 
shown  that  this  inflammation  in  infancy  may  occasion  imperfect  development 


GOXORRHCEA  IX  WOMEN  AND  CHILDREN  227 

of  the  genitalia,  sterility,  and  chronic  invaUdism  in  later  life.  The  local  con- 
ditions are  apt  to  be  rebellious  to  treatment. 

Treatment. — In  the  early  stages  of  the  disease,  when  the  symptoms  are  very 
acute,  the  child  should  be  kept  in  bed,  or  at  least  her  activity  should  be 
lessened.  Polyvalent  stock  bacterins  seem  to  be  the  most  powerful  means  at 
our  disposal  for  overcoming  this  infection.  They  should  be  given  in  doses  of 
two  to  ten  million  at  intervals  of  from  four  days  to  a  week,  in  the  absence  of 
reactions.  In  connection  with  this  treatment  the  genitalia  should  be  kept  clean 
by  simple  external  lavage.  Should  bacterins  not  be  available,  or  should  they 
fail  to  produce  a  cure  after  two  to  six  months'  use,  vaginal  irrigations  should 
be  employed.  These  are  to  be  given  by  means  of  a  soft-rubber  catheter  inserted 
into  the  vagina.  Any  of  the  solutions  suitable  for  use  in  the  bladder  may  be 
used;  those  in  most  favor  are  potassium  permanganate,  protargol,  boric  and 
salicylic  acids  (ten  grains  of  the  first  and  five  of  the  second  being  used  to  the 
ounce),  and  carbolic  acid  (1  to  200).  These  lotions  act  better  if  they  are 
preceded  by  a  cleansing  douche  of  1  per  cent,  sodium  bicarbonate.  Irrigations 
and  topical  applications  do  most  good  in  the  older  children:  as  puberty  is 
approached,  and  after  that  time,  they  are  preferable  to  bacterins. 

If  these  injections  cause  pain  they  must  be  weakened  until  they  are  borne 
well.  As  the  acute  stage  passes  they  are  gradually  strengthened,  hydrastis 
being  added.  For  the  accompanying  urethritis  small  doses  of  salol  and  boric 
acid  are  indicated;  the  prescriptions  given  on  page  198  can  be  advantageously 
used. 

The  general  health  should  receive  careful  attention,  and  in  strumous  or 
cachectic  patients  treatment  may  have  to  be  prolonged  for  weeks  or  months 
before  cure  is  effected. 


CHAPTER  XII 

COMPLICATIONS  OF  GONORRHCEA 

In  the  large  majority  of  patients  suffering  from  urethritis,  when  treatment 
has  been  judiciously  instituted  from  the  beginning  of  the  attack,  there  are  no 
comphcations;  that  is,  the  disease  is  Hmited  to  the  urethra,  or  to  the  urethra 
and  prostate.  Exceptionalh'  the  inflammation  exhibits  a  tendency  to  extend 
wide  of  the  urethra,  or  even  to  attack  other  parts  of  the  body.  In  these  cases 
there  is  often  a  mixed  infection,  the  ordinary  pus  microbes  being  present  and 
producing  either  local  inflammations  or  a  mild  or  severe  form  of  septic  poison- 
ing, though  there  is  e\-idence  that  the  gonococcus  in  itself  or  the  poisons  engen- 
dered by  it  may  produce  many  of  these  complications. 

There  is  an  individual  susceptibility  toward  the  development  of  complica- 
tions, some  patients  never  passing  through  a  simple,  uncomplicated  attack. 

As  to  the  cause  of  complications,  all  factors  which  tend  to  exacerbate  an 
attack  of  gonorrhoea  predispose  to  complications.  The  fact  that  some  of  these 
comphcations  ma}^  be  due  to  a  mixed  infection  should  be  borne  in  mind  as  in- 
dicating the  necessit}^  for  perfect  cleanhness  in  all  local  manipulations. 

In  the  male  the  complications  caused  by  gonorrhoea  are:  (1)  balanitis 
and  balanoposthitis;  (2)  phimosis  and  paraphimosis;  (3)  lymphangitis  and 
l\Tnphadenitis ;  (4)  follicuhtis  and  periurethral  abscess;  (5)  cowperitis;  (6) 
prostatitis  (so  common  that  it  is  hardh^  proper  to  call  it  a  comphcation) ;  (7) 
vesicuHtis  seminahs;    (8)  epididymitis. 

Both  sexes  are  subject  to:  (1)  cystitis;  (2)  ureteritis  and  ureteropyelitis; 
(3)  conjunctivitis;  (4)  metastatic  gonorrhoea,  including  such  manifestations 
as  arthritis,  endocarditis,  and  meningitis. 

Balanitis  and  Balanopostkitis. — Though  gonococci  seem  to  play  no  rcle 
in  the  production  of  balanitis,  or  inflammation  of  the  surface  of  the  glans  penis, 
this  is  a  frequent  complication  of  gonorrhoea. 

The  symptoms,  diagnosis,  and  treatment  have  already  been  described,  the 
gonorrhoeal  form  of  the  affection  running  a  course  which  does  not  differ  from 
that  due  to  other  causes  (see  p.  108). 

PHrsiosis,  inflammator}'  in  character  and  secondary  to  balanoposthitis  (Fig. 
115),  has  been  described  (see  p.  98).  This  is  always  a  troublesome  condition, 
since  it  materially  interferes  vriih.  treatment  and  may  render  the  diagnosis 
exceedingly  difficult.  Swelling  may  become  so  great  that  a  certain  amount  of 
sloughing  occurs.  The  inflammatory  induration  usualh^  entirely  disappears. 
It  may  remain,  leaving  a  thickened  prepuce,  which  is  readily  fissured  and  eroded. 

If  the  patient  first  comes  under  treatment  vnth  a  vague  history  and  with 
an  oedematous  swollen  prepuce  from  the  orifice  of  which  flow  blood  and  pus, 
it  is  sometimes  difficult  to  determine  correctly  the  source  and  nature  of  the 
discharge. 

\Miether  or  not  all  the  discharge  comes  from  the  preputial  sac  or  a  part  of 
228 


COMPLICATIONS  OF  GONORRHCEA 


229 


it  from  the  urethra  can  be  ascertained  by  having  the  patient  urinate  after  the 
preputial  sac  has  been  thoroughly  cleansed  by  careful  syringing. 

Paraphimosis. — This  is  dependent  upon  inflammatory  swelling  of  the  fore- 
skin, due  either  to  balanoposthitis  or  to  the  urethral  inflammation  (Fig.  116), 
which,  after  rolling  back  or  being  forced  back,  can  no  longer  be  brought  for- 


FiG.  115. — Gonorrhcea)  phimosis. 


Fig.  116. — Guiiurrhijjal  paraphimosis. 

ward.  The  question  of  differential  diagnosis  is  scarcely  raised  here,  since  the 
urethral  meatus  is  freely  exposed  and  the  discharge  can  be  seen  escaping 
through  it.     The  treatment  has  been  described  (see  p.  102). 

Lymphangitis. — In  a  small  percentage  of  gonorrhoeal  cases  a  simple  lym- 
phangitis or  inflammation  of  the  lymphatic  vessels  occurs. 


230 


GENITO-URINARY  SURGERY 


The  complication  arises  sometimes  in  cases  of  little  severity,  but  usually 
when  the  urethral  inflammation  is  unusually  acute.  Qeanliness  and  the  avoid- 
ance of  dressings  which  prevent  the  escape  of  pus  from  the  urethra  are  the 
prophylactic  measures  to  be  employed. 

Lymphadenitis  or  Bubo. — Inflammation  of  the  inguinal  nodes,  or  bubo,  is 
a  comparatively  rare  complication  of  gonorrhoea. 

It  is  commonly  excited  by  excesses,  exposure,  or  violent  and  long-continued 
exertion.  Persons  who  are  much  on  their  feet  suffer  more  frequently  from 
this  complication  than  those  whose  occupation  allows  of  more  rest.  The  node 
usually  affected  is  one  of  the  superficial  set  lying  just  below  Poupart's  ligament, 
embedded  in  the  subcutaneous  cellular  tissue  and  placed  above  the  fascia  lata. 

Symptoms. — A  small,  painful  tumor  makes  its  appearance  in  the  groin 
(Fig.  117);  it  is  tender  on  pressure,  and  the  pain  is  aggravated  by  standing 


Fig.  117. — Bilateral  gonorrhoeal  buboes. 


Fig.    118. — Periurethral   abscess;    marked   swell- 
ing of  prepuce. 


or  walking.  It  is  at  first  freely  movable  beneath  the  skin,  but  afterwards  con- 
tracts adhesions  to  the  latter  and  to  the  surrounding  parts,  and  becomes  doughy 
in  feel  and  reddened  or  purplish  in  hue.  The  majority  of  these  cases  after 
reaching  this  condition  will  subside  under  appropriate  treatment,  disappearing 
in  time.  In  some  instances,  however,  particularly  in  patients  of  scrofulous  ten- 
dencies or  in  those  whose  vitality  is  lessened  through  bad  habits  or  overwork, 
suppuration  ensues,  ushered  in  by  the  local  and  general  phenomena  of  abscess- 
formation.  The  discharge  from  a  suppurative  gonorrhceal  bubo  does  not  con- 
tain gonococci. 

The  treatment  is  that  of  adenitis  from  other  causes  (see  p.  129).  Complete 
removal  of  gonorrhoeal  buboes  before  they  have  broken  down  is  justifiable,  pro- 
vided they  become  progressively  worse  in  spite  of  one  or  two  days'  careful 
treatment. 

Folliculitis  and  Periurethral  Abscess. — Gonorrhoeal  inflammation  not 
only  spreads  along  the  surface  of  the  urethra,  but,  dipping  into  the  mucous 


COMPLICATIONS  OF  GONORRHCEA  231 

follicles  and  gland  ducts,  involves  their  entire  mucous  surface.  Often  if  the 
finger  is  passed  along  the  under  surface  of  the  urethra  there  can  be  felt  distinct 
nodulations,  due  to  the  follicular  swelling.  At  the  meatus,  where  the  glands 
and  follicles  are  especially  well  developed,  pus  may  be  seen  to  escape  from  their 
orifices  on  pressure. 

If  the  ducts  become  closed  from  swelling  or  from  inflammatory  exudation, 
the  catarrhal  secretion  of  the  follicles  being  no  longer  able  to  escape  into  the 
urethra,  small  pockets  of  pus,  or  follicular  abscesses,  appear.  These  follicular 
abscesses  are  most  frequently  located  in  the  first  inch  of  the  urethra,  the  follicles 
being  numerous  in  this  region.  They  appear  as  small,  round,  tender  nodules, 
which  may  open  internally  without  involving  the  skin,  the  duct  finally  becoming 
patulous.  Frequently,  however,  the  skin  reddens  and  is  no  longer  movable  over 
the  nodule,  and  the  latter  discharges  its  contents  externally.  In  this  case  the 
urethral  opening  of  the  gland  usually  remains  closed,  and  no  fistula  results. 
The  fraenum  is  apt  to  be  markedly  cedematous  during  the  period  of  pus-forma- 
tion in  the  follicles  lying  near  its  point  of  attachment  behind  and  below  the 
meatus.  On  stripping  back  the  foreskin  the  projecting  swelling  is  readily  seen 
entirely  obliterating  the  normal  depression  situated  at  the  side  of  the  fraenal 
attachment.  When  external  rupture  and  discharge  of  pus  take  place,  a  trouble- 
some sinus  is  often  left. 

Sometimes  the  lacuna  magna  remains  in  an  inflammatory  condition  long 
after  the  urethral  mucous  membrane  has  returned  to  a  healthy  state.  The 
opening  of  this  follicle  is  so  large  that  it  is  not  readily  obliterated,  yet  it  may  be 
narrowed  to  such  an  extent  that  healing  injections  do  not  penetrate  to  its 
deeper  portions.    Such  an  inflammation  will  occasion  a  long-continued  discharge. 

At  the  frsenum  the  mucous  follicles  are  surrounded  by  fibrous  tissue:  hence 
abscess-formation  is  limited.  Farther  back  along  the  urethra  this  investment 
of  connective  tissue  is  less  marked:  hence  the  inflammation  may  readily  extend 
into  the  cavernous  tissue,  and  in  case  the  inflammation  goes  on  to  suppuration, 
periurethral  abscess  will  be  formed. 

Periurethral  abscess  begins  as  a  case  of  folliculitis  or  adenitis,  but  the  swell- 
ing rapidly  increases,  and  is  attended  with  pain,  tenderness,  and  often  some 
diminution  in  the  size  of  the  stream  passed  during  urination.  The  swelling 
may  suddenly  subside  from  opening  of  the  obstructed  duct.  This  is  usually 
denoted  by  diminution  in  the  size  and  tension  of  the  tumor,  by  blood  and  pus 
in  the  urine,  and  by  a  sense  of  relief  from  pain.  The  subsidence  may  inaugurate 
a  speedy  cure,  or  may  be  shortly  followed  by  urinary  extravasation.  Commonly 
the  skin  becomes  reddened  and  inflamed,  and  the  pus  is  evacuated  externally, 
after  which  the  abscess-cavity  heals  (Fig.  118). 

If  the  abscess  opens  externally  and  internally  at  the  same  time,  a  urinary 
fistula  results,  and  one  difficult  to  cure. 

Periurethral  abscesses  occur  at  any  portion  of  the  anterior  urethra,  but  are 
most  frequently  observed  in  the  region  of  the  bulb.  They  may  be  attended  with 
considerable  inflammatory  induration  of  the  corpus  spongiosum,  which  may 
ultimately  undergo  complete  resolution,  or  may  remain  permanently,  consti- 
tuting an  incurable  chordee  and  preventing  intercourse. 


232  GENITO-URINARY  SURGERY 

When  urinary  extravasation  occurs  it  is  attended  by  rapid  increase  in  pain 
and  swelling,  and  infiltration  of  sometimes  the  greater  portion  of  the  corpus 
spongiosum.  The  local  pain  is  much  increased  during  each  urination.  There 
is  commonly  an  opening  formed  externally,  which  allows  of  free  purulent  dis- 
charge and  results  in  urinary  fistula.  Sometimes  an  extensive  sloughing  process 
is  inaugurated,  attended  with  well-marked  general  septic  symptoms.  Even  ia 
the  mildest  case  of  urinary  extravasation  there  may  be  sufficient  destruction 
of  the  erectile  tissue  of  the  spongy  body  to  cause  great  deformity  of  the 
penis  when  the  organ  is  erect. 

Treatment. — Gentle  pressure  and  massage  are  sometimes  successful  in  ren- 
dering patulous  the  obstructed  duct  of  an  inflamed  gland  or  follicle,'  or  the 
purulent  collection  may  be  incised  through  an  urethroscope.  When  the  swelhng 
becomes  marked  and  painful,  cloths  wet  with  alcohol  and  lead  water  should 
be  kept  about  the  penis.  When  the  skin  becomes  adherent  and  softening 
occurs,  the  follicles  should  be  opened,  curetted,  and  packed  with  iodoform 
gauze.  They  usually  heal  kindly  from  the  bottom.  When  they  have  ruptured 
spontaneously,  causing  a  troublesome  sinus,  this  should  be  converted  into  an 
open  wound,  and  be  curetted  and  packed.  When  there  are  both  internal  and 
external  openings,  the  formation  of  a  permanent  fistula  is  guarded  against  by 
permanent  or  intermittent  catheterization,  no  urine  being  allowed  to  escape 
through  the  -artificial  opening.  Fistulse  at  times  heal  spontaneously.  If  not,  a 
plastic  operation  is  indicated. 

When  the  lacuna  magna  becomes  involved  in  a  chronic  inflammation,  which, 
though  not  going  on  to  abscess-formation,  persists  and  keeps  up  discharge,  a 
fine  grooved  director  should  be  passed  to  its  deepest  part,  and  it  should  be 
slit  out  into  the  urethra. 

Periurethral  abscess  when  onCe  formed  demands  immediate  evacuation,  and 
this  indication  is  even  more  imperative  when  there  is  urinary  extravasation. 
The  formation  of  a  fistula  is  guarded  against  by  permanent  catheterization. 

Prostatitis. — Prostatitis  exists  in  some  degree  in  practically  every  case  in 
which  the  posterior  urethra  is  invaded.  It  is  therefore  to  be  regarded  rather  as 
one  of  the  typical  features  of  the  disease  than  as  a  complication.  The  follicles 
and  glandular  elements  of  this  body  are  the  structures  chiefly  involved,  the 
muscular  tissue,  forming  the  greater  portion  of  its  mass,  remaining  unaffected, 
except  in  the  most  severe  cases. 

Simple  acute  prostatitis  represents  the  mildest  form  of  acute  prostatitis.  It 
is  probably  present  to  a  minor  degree  in  every  case  of  acute  posterior  urethritis, 
and  represents  little  more  than  inflammatory  hypersemia. 

Acute  follicular  prostatitis  is  usually  due  to  some  cause  exciting  renewed 
intensity  of  gonorrhoeal  inflammation,  such  as  excessive  drinking  or  coitus. 

The  patient  complains  of  burning  during  urination,  and  sharp,  shooting, 
clearly  localized  pains  during  the  passage  of  the  last  drops.  These  pains  are 
located  in  the  deep  urethra.  On  rectal  examination  the  prostate  is  found  to  be 
not  materially  enlarged,  but  presenting  one  or  two  well-defined  nodules,  usually  in 
one  lobe  only.  These  are  intensely  indurated,  contrasting  markedly  with  the 
soft  condition  of  the  remainder  of  the  gland,  and  are  painful  on  pressure.  The 
inflammation  is  confined  to  the  follicles  and  the  perifoflicular  tissues. 


COMPLICATIONS  OF  GONORRHCEA 


233 


Parenchymatous  prostatitis,  after  it  runs  on  to  suppuration,  is  the  most  seri- 
ous form  of  the  affection.  The  whole  structure  of  the  gland  is  involved.  There 
is  not  only  great  infiammalory  hyperaemia,  but  also  marked  exudation.  The 
constitutional  reaction  is  pronounced. 

The  abscess  usually  ruptures  into  the  urethra.  This  will  be  denoted  by 
aggravation  of  the  pain  during  the  act  of  defecation  or  of  micturition,  followed 
by  a  free  discharge  of  blood  and  pus  through  the  urethra,  and  the  immediate 
amelioration  of  all  the  symptoms.  This  is  considered  the  most  immediately 
favorable,  and  is  the  common  termination;  it  may  be  followed  by  urinary  extrav- 
asation, requiring  operation,  but  this  is  unusual. 

The  pus  may  penetrate  the  capsule  of  the  gland  at  any  point.  If  it  is  not 
evacuated  into  the  urethra,  it  is  prone 
to  rupture  into  the  rectum.  If  it 
does  not  open  into  either  the  rectum 
or  the  urethra,  it  generally  burrows 
into  the  perineum  or  the  ischiorectal 
fossa.  It  may  burrow  in  almost  any 
direction,  cases  being  recorded  in 
which  it  opened  through  the  sciatic 
foramen,  at  the  edge  of  the  false  ribs, 
and  into  the  abdominal  cavity. 

At  times  prostatic  abscesses  de- 
velop in  so  quiet  a  manner  as  to  es- 
cape observation,  with  no  symptoms 
other  than  those  commonly  noted  in 
the  congestive  form  of  the  disease, 
which  may  be  so  slight  that  the 
patient  makes  no  complaint.  After 
some  days  the  symptoms  of  septic 
absorption,  characterized  by  rigors 
and  fever,  set  in;  and  examination  by 
the  rectum  shows  a  large  fluctuating 
swelling.  Hence  in  all  cases  of 
urethritis  attended  by  undue  sys- 
temic disturbance,  examination  should  be  made  to  discover  whether  or  not  this 
insidious-form  of  prostatic  trouble  is  developing.  (For  symptoms,  diagnosis,  and 
treatment  of  prostatitis,  see  page  386,  et  seq.) 

Vesiculitis. — Vesiculitis,  or  inflam.mation  of  the  seminal  vesicles,  occurs  as 
a  complication  of  acute  posterior  urethritis  in  a  much  larger  percentage  of  cases 
than  is  generally  imagined,  the  symptoms  differing  so  slightly  from  those  of 
inflammation  of  the  prostate  that  the  involvement  of  the  seminal  vesicles  is  not 
suspected  unless  a  rectal  examination  is  made.  (See  section  on  Seminal  Vesicles, 
p.  375.) 

Epididymitis. — From  an  anatomical  consideration  of  the  ejaculatory  duct, 
vas  deferens,  and  epididymis,  it  is  easy  to  understand  how  by  direct  continuity 
inflammations  of  the  prostatic  urethra  may  travel  to  the  epididymis. 

Epididymitis  rarely  develops  before  the  third  week  of  gonorrhoea.     Most  of 


Fig.  119. — Epididymitis  with  hydrocele.  Gono- 
cocci  in  small  numbers  were  found  in  the  ten  cubic 
centimetres  of  slightly  cloudy  fluid  removed  from 
the  vaginal  sac.  Pain  was  markedly  relieved  by 
aspiration  of  the  fluid. 


234  GENITO-URINARY  SURGERY 

the  cases  begin  in  the  fourth  or  fifth  week  of  the  disease.  It  may  occur  within 
three  days  of  the  onset  of  urethritis  or  not  till  a  gleet  has  run  a  course  of 
several  years. 

It  is  due  primarily  to  involvement  of  the  posterior  urethra  in  the  gonorrhceal 
process;  secondarily,  to  any  cause  which,  by  increasing  the  violence  of  this  in- 
flammation, may  favor  its  extension  to  the  ejaculatory  ducts  and  the  vas: 
neglect  of  treatment,  venereal  excitement,  coitus,  exposure  to  cold,  drinking, 
and  violent  exertion,  all  the  causes  which  aggravate  posterior  urethritis,  also 
render  more  probable  the  onset  of  epididymitis.  Irritating  injections  or  instru- 
mentation during  the  acute  stage  of  a  posterior  urethritis  frequently  cause 
epididymitis.  Of  all  these  causes  those  most  commonly  operative  are  neglect 
of  treatment  and  coitus. 

The  disease  is  usually  unilateral,  and  seems  to  affect  the  two  sides  with 
about  equal  frequency  (Fig.  119)  (see  section  on  "  Epididymitis,"  p.  316). 

EXTRAGENITAL  AND  SYSTEMIC  GONORRHGEA 

As  a  rule  secondary  to  urethral  infection  in  the  same  individual,  gonorrhoea 
exceptionally  affects  structures  other  than  the  genital  tract,  by  predilection  those 
covered  with  columnar  epithelium  and  by  endothelium,  as  the  rectum  con- 
junctiva, peritoneum,  synovial  sheaths,  meninges,  peri-  and  endocardium,  blood- 
vessels, and  pleura.  Though  stratified  pavement  epithelium  resists  for  a  time 
gonococcal  invasion,  gonorrhceal  cystitis  and  stomatitis  are  exceptionally 
observed. 

Cystitis. — Until  the  nature  of  posterior  urethritis  was  clearly  defined  it  was 
common  to  attribute  the  symptoms  attendant  upon  this  inflammation  to  involve- 
ment of  the  neck  of  the  bladder.  The  possibility  of  extension  of  posterior 
urethritis  to  the  vesical  mucous  membrane  cannot  be  denied,  and  any  one  of 
the  many  causes  which  aggravate  the  original  disease  may  occasion  such  exten- 
sion. The  inflammation  rarely  spreads  far  from  the  internal  orifice  of  the 
urethra,  being  usually  limited  rather  sharply  to  the  trigone.  In  the  great 
majority  of  cases  it  is  due  to  mixed  infection,  the  gonococci  themselves  appar- 
ently not  readily  infecting  the  mucous  membrane  of  the  bladder.  Involvement 
of  the  entire  vesical  mucosa  is  extremely  rare.  The  subjective  symptoms  are 
so  like  those  of  posterior  urethritis  that  on  these  alone  a  differential  diagnosis 
can  scarcely  be  made  (see  chapter  on  "  Cystitis,"  p.  488). 

This  condition  is  difficult  to  cure,  pathological  alterations  taking-  place  in 
the  vesical  mucosa,  and,  indeed,  in  the  whole  thickness  of  the  bladder  walls, 
which  are  liable  permanently  to  cripple  this  viscus. 

The  general  treatment  appropriate  to  acute  posterior  urethritis  and  to 
prostatitis  requires  no  material  alteration  when  it  becomes  clear  that  the  vesical 
mucosa  is  involved  in  the  inflammation. 

Ureteritis,  Pyelitis,  and  Nephritis. — These  rare  complications  are  the 
results  either  of  direct  extension  of  the  inflammatory  process,  or  of  the  gonococci 
being  carried  to  the  kidney  by  the  blood,  or  possibly  through  the  lymph-chan- 
nels.   An  epididymitis  is  very  often  the  source  of  haematogenous  infection. 

Ureteritis  and  pyelitis  are  usually  associated,  and  are  recognized  by  the 
examination  of   the  urine   obtained   by   catheterization.     Symptoms  may  be 


COMPLICATIONS  OF  GONORRHCEA  235 

entirely  wanting  except  for  the  persistent  pyuria  with  recurrent  attacks  of 
urethritis,  or  there  may  be  vague  pain  in  the  loin,  or  a  history  of  distress  in 
this  region. 

Nephritis  probably  results  more  often  from  hsematogenous  infection  than 
from  direct  extension  of  the  disease.  The  onset  may  be  insidious  or  sudden, 
and  the  attack  mild  or  severe.  Many  of  the  milder  forms  of  the  affection  escape 
notice  altogether,  the  only  symptom  having  been  a  transient  albuminuria.  In 
the  more  severe  cases  there  is  marked  prostration,  with  fever  and  the  associated 
symptoms.  There  are  pain  and  tenderness  in  the  loin;  local  or  generalized 
oedema  may  be  present.  The  urine  is  at  first  reduced  in  quantity,  and  later 
increased. 

Treatment. — Gonorrhceal  nephritis  calls  for  treatment  similar  to  that  suit- 
able for  nephritis  from  other  causes.  Cups  and  hot  compresses  to  the  loins 
are  particularly  indicated.  Should  pus  form,  a  very  rare  circumstance,  nephrot- 
omy is  demanded. 

Pyelitis  and  ureteritis,  whether  the  results  of  direct  extension  or  a  residual 
lesion  of  nephritis,  are  best  treated  by  lavage  by  means  of  a  small  ureteral 
catheter  with  such  solutions  as  are  used  in  the  bladder. 

GoNORRHOZA  OF  THE  Rectum. — Gouorrhoeal  inflammation  of  the  rectal 
mucous  membrane  is  observed  more  frequently  in  women  than  in  men,  mainly 
because  women  are  more  exposed  to  infection  from  the  backward  trickling  of 
gonococcus-bearing  secretions  from  the  vulva  and  vagina.  The  disease  can  be 
excited  by  unnatural  practices. 

Symptoms. — The  symptoms  are  those  of  acute  inflammation.  There  are 
free  discharge  of  blood-stained  pus,  tenesmus,  painful  defecation,  and  on  direct 
examination  acute  redness  and  infiltration  of  the  mucous  membrane,  with 
excoriations  about  the  anal  orifice.  The  disease  is  prone  to  become  chronic, 
leaving  on  subsidence  of  the  general  inflammation  one  or  more  localized  ulcers. 
These,  if  allowed  to  extend,  may  ultimately  cause  dense  cicatrices. 

The  diagnosis  is,  of  course,  founded  upon  the  presence  of  the  gonococcus, 
together  with  a  history  of  infection. 

The  treatment  consists  in  relieving  the  tenesmus  and  burning  pain  of  the 
early  stages,  in  frequent  cleansing  of  the  mucous  membrane  of  the  affected 
surfaces,  and  in  applying  astringent  and  antiseptic  medications. 

For  the  rehef  of  pain  and  tenesmus,  suppositories  containing  a  grain  of 
the  watery  extract  of  opium,  a  quarter  of  a  grain  of  cocaine,  and  a  quarter 
of  a  grain  of  belladonna  will  be  sufficient. 

The  rectum  should  be  cleaned  at  least  twice  a  day  by  means  of  a  hot 
douche  of  corrosive  sublimate  1  to  20,000,  or  protargol  1  to  1000,  or,  if  these 
solutions  occasion  severe  pain,  by  a  saturated  solution  of  boric  acid. 

When  the  acute  symptoms  have  subsided,  strong  solutions  of  silver  nitrate 
are  employed,  1  to  1000  and  1  to  500,  in  smaller  quantities.  When  the  general 
catarrh  is  cured,  leaving  only  ulcers  or  hyperaemic  patches,  these  are  touched 
directly  with  a  strong  solution  of  silver  nitrate  (ten  per  cent.),  or  with  one 
of  the  other  agents  already  mentioned  in  the  treatment  of  chronic  gonorrhoea. 

In  some  cases,  when  a  discharge  persists,  a  two  per  cent,  solution  of  alum  or 
of  tannin  injected  into  the  rectum  will  prove  serviceable. 


236  GENITO-URINARY  SURGERY 

Gonorrh(I:a  of  the  Mouth,  though  of  exceeding  rarity,  has  been  observed 
as  an  acute  stomatitis,  in  the  discharges  of  which  were  found  gonococci. 

GONORRHCEA  OF  THE  EYE 

GoNORRHCEAL  CONJUNCTIVITIS. — Pufulent  Ophthalmia;  Gonorrhoeal  Oph- 
thalmia; Acute  Blennorrhoca  in  Adults. — This  is  a  violent  inflammation  of  the 
conjunctiva,  characterized,  in  its  usual  form,  by  great  swelHng  of  the  hds,  serous 
infiltration  of  the  bulbar  conjunctiva,  and  the  free  secretion  of  contagious  pus. 

Cause. — The  source  of  contagion  can  usually  be  traced  to  an  acute  gonor- 
rhoea or  gleet,  or  to  an  eye  similarly  affected,  soiled  fingers  or  linen  being  the 
usual  means  of  transmission. 

The  gonococci  of  Neisser  are  present  in  great  abundance  during  the  purulent 
stage,  being  found  within  the  cells.    They  penetrate  the  epithelium  and  enter  the 


Fig.    120. — Gonorrhoeal  conjunctivitis.     Swelling  of  the  lids  and  free 
discharge. 

lymph-spaces  of  the  subconjunctival  tissue.  The  secretion  from  vaginal  leucor- 
rhoea,  which  is  not  uncommon  in  young  girls,  may  produce  a  conjunctivitis  of 
very  analogous  type. 

Symptoms.- — The  symptoms  appear  from  twelve  to  forty-eight  hours  after 
inoculation,  and  at  first  resemble  those  of  an  ordinary  catarrhal  conjunctivitis. 
They  speedily  give  place  to  great  swelling  of  the  lids  (Fig.  120),  intense  con- 
gestion and  chemosis  of  the  bulbar  conjunctiva,  which  forms  a  ring  of  infiltration 
around  the  cornea,  and  thickening  of  the  palpebral  conjunctiva,  which  becomes 
rough  and  dark  red  in  color,  and  is  dotted  over  with  spots  of  ecchymosis 
(Fig.  121).  The  slightly  turbid  discharge  of  the  early  staee  chane;es  to  a  yellow 
or  greenish-yellow  pus,  which  is  secreted  in  great  quantities.     The  vitality  of 


COMPLICATIONS  OF  GONORRHCEA 


237 


the  cornea  is  soon  threatened,  and,  unless  the  disease  is  properly  managed, 
ulcers  form,  either  small,  oval  lesions  near  the  margin  of  the  cornea,  or  larger 
ones  at  its  centre.  These  may  terminate  in  healing,  or  perforation  may  take 
place.  In  the  event  of  the  latter  mishap,  incarceration  of  the  iris  in  the  wound 
and  the  formation  of  an  adherent  scar  or  leucoma  result.  This  scar  may  bulge 
forward  and  form  a  partial  anterior  staphyloma,  or,  if  the  prolapse  has  been 
an  extensive  one,  the  whole  cornea  is  involved,  and  the  protruding  cicatrix  is 
known  as  a  total  staphyloma.  In  bad  cases  the  inflammation  travels  through 
all  the  tissues  of  the  eyeball,  which  passes  into  a  state  of  general  inflammation 
or  panophthalmitis  (Fig.  122),  ending  in  atrophy  and  shrinking  of  the  bulb. 

Gonorrhoeal  ophthalmia  neonatorum,  due  to  gonococcic  infection  from  the 
genital  tract  of  the  mother,  has  an  incubation  of  two  or  three  days  and  is  often 


FiGi    121. — Gonorrhoeal    conjunctivitis.      Infiltration    of    bulbar    and 
palpebral  conjunctiva. 

bilateral.  The  inflammatory  symptoms  are  those  characteristic  of  the  infection 
in  the  adult,  but  less  intense  and  rapidly  destructive. 

Gonorrhoeal  conjunctivitis  reaches  its  height  in  about  ten  days,  and  then 
gradually  subsides  in  from  one  to  two  months.  Sometimes  it  passes  into  a 
chronic  type  of  inflammation,  with  great  redness  of  the  palpebral  conjunctiva 
and  hypertrophy  of  the  papillae.  One  eye  is  usually  first  affected;  the  other 
may  escape  or  may  be  subsequently  inoculated;  sometimes,  however,  both 
organs  are  simultaneously  inflamed. 

Diagnosis. — This  acute  infection  must  be  distinguished  from  gonorrhoea! 
rheumatic  ophthalmia  in  the  adult  (see  table,  p.  240),  and  from  chemical  or 
traumatic  conjunctivitis  in  the  new-born  incident  to  bichloride  vaginal  injection 
of  the  mother,  or  prophylactic  silver  instillations  to  the  eyes  of  the  infant; 


238  GEXITO-URIXARY  SURGERY 

the  chemical  conjunctivitis  is  rapid  in  onset,  brief  in  course,  and  gonococci  are 
not  found  in  the  discharge. 

Prognosis. — This  is  always  grave,  and,  unless  the  disease  is  treated  from 
its  incipiency,  corneal  scars,  or  the  more  serious  sequelae  of  perforation  which 
have  just  been  described,  are  likely  to  result. 

Treatment. — Every  case  of  true  gonorrhoeal  conjunctivitis  should  be  iso- 
lated. Patients  suffering  from  gonorrhoea  should  be  warned  of  the  danger  of 
infecting  their  eyes  and  the  eyes  of  those  around  them.  As  usually  one  eye 
alone  is  affected,  the  other  may  be  protected  by  sealing  it  \^ath  an  antiseptic 
bandage  the  edges  of  which  are  made  secure  by  fastening  along  them  strips  of 
gauze  painted  with  flexible  collodion,  or  by  the  application  of  Buller's  shield, 
which  consists  of  a  watch-glass  of  the  ordinary  form  fitted  in  a  square  piece  of 


'^{-'i. 


Fig.  122. — Gonorrhoeal  conjunctivitis  passing  into  a  panophthalmitis. 

rubber  adhesive  plaster,  which  is  carefully  applied  to  the  brow,  temple,  lower 
margin  of  the  orbit,  and  nose,  and  secured  with  additional  strips  to  prevent  the 
discharge  from  getting  under  the  edges.  The  watch-glass  is  directly  in  front 
of  the  eye  and  permits  its  inspection.  Great  care  must  be  exercised  in  applying 
this  bandage,  because  if  any  of  the  discharge  should  be  confined  beneath  it, 
or  in  any  way  should  find  entrance  under  the  edges  of  the  plaster,  the  chance 
of  infection  would  be  greater  than  wathout  the  bandage.  Gonorrhceal  con- 
junctivitis of  the  new-born  is  guarded  against  by  instilling  in  each  eye  imme- 
diately after  birth  a  few  drops  of  a  five  per  cent,  solution  of  protargol  or  a  one 
per  cent,  solution  of  silver  nitrate.  The  curative  treatment  both  in  infants 
and  adults  is  as  follows:  During  the  earlier  stages  cold  is  the  most  useful  agent. 
This  may  be  aonlied  bv  means  of  Leiter's  tubes,  but  it  is  more  convenient  to 
place  upon  a  block  of  ice  square  compresses  of  patent  lint,  which  in  turn  are 


COMPLICATIONS  OF  GONORRHCEA  239 

laid  upon  the  swollen  lids  and  as  frequently  changed  as  may  be  needful  to  keep 
up  a  uniform  cold  impression. 

The  discharge  should  be  frequently  removed.  This  may  be  done  by  irri- 
gating the  conjunctival  cul-de-sac  at  intervals  of  not  more  than  half  an  hour 
with  a  saturated  solution  of  boric  acid  or  a  solution  of  bichloride  of  mercury 
1  to  8000.  It  is  a  mistake  to  use  strong  solutions  of  sublimate  in  the  treatment 
of  this  disease,  because  they  increase  the  liability  of  the  cornea  to  ulceration, 
and,  moreover,  it  is  not  possible  to  employ  them  in  such  strength  that  the 
germicidal  properties  of  this  drug  will  be  efficient. 

Silver  nitrate  is  the  best  of  all  remedies.  The  lids  should  be  thoroughly 
everted  without  pressure  upon  the  globe,  the  inflamed  conjunctiva  freed  from 
all  secretion,  and  a  solution  of  this  drug,  five  grains  to  the  ounce,  applied 
with  a  cotton  mop  or  camel's-hair  brush  to  the  exposed  surfaces,  or  simply 
dropped  upon  them.  The  lids  are  then  returned  to  their  place.  This  application 
is  made  once  in  twenty-four  hours.  In  the  more  severe  cases  a  drop  of  1  to 
500  silver  nitrate  should  be  placed  in  the  eye  every  two  hours. 

If  corneal  haziness  appears,  or  a  central  ulcer  forms,  atropine  drops,  four 
grains  to  the  ounce,  should  be  instilled  every  three  or  four  hours;  a  marginal 
ulcer,  with  a  tendency  to  perforate,  may  be  treated  in  like  manner  with  a  solu- 
tion of  eserine,  one-sixth  to  one-half  grain  to  the  ounce,  or,  as  this  drug,  while 
it  has  distinct  value  in  preventing  sloughing  of  the  cornea,  tends  to  increase 
the  hyperaemia  of  the  iris  and  the  tendency  to  the  production  of  iritis,  it  may 
be  used  every  four  hours  during  the  day  and  a  drop  or  two  of  the  atropine 
solution  at  night. 

If  the  chemosis  of  the  conjunctiva  is  very  great,  scarification  maj^  be  tried, 
and  will  occasionally  be  beneficial.  Great  swelling  of  the  lids,  tending  by  their 
pressure  to  endanger  further  the  nutrition  of  the  cornea,  may  be  relieved  by 
canthotomy, — that  is,  by  cutting  through  the  external  commissure  of  the  affected 
eye. 

During  the  stage  of  corneal  ulceration,  should  it  occur,  the  cold  applications 
previously  described  may  be  substituted  by  hot  fomentations  applied  by  means 
of  squares  of  antiseptic  gauze  wrung  out  of  carbolized  water  of  a  temperature 
of  120°  F.  and  frequently  changed.  These  applications  are  useless  unless  they 
are  realh^  hot. 

Many  other  drugs  in  addition  to  those  named  have  been  used  for  irrigating 
the  conjunctival  cul-de-sac.  Of  these,  the  most  important  are  mercuric  cyanide 
1  to  1500,  protargol  1  to  2000,  hydrogen  peroxide,  aluminum  sulphate  eight 
grains  to  the  ounce,  carbolic  acid  one-half  to  five  per  cent.,  and  potassium 
permanganate.  Of  the  last-named  drug  a  tepid  solution  1  to  5000  should  be 
prepared,  and  the  conjunctival  cul-de-sac  freely  flushed  twice  a  day,  at  least 
one  litre  being  employed  at  each  irrigation.  The  irrigations  are  best  given  with 
the  aid  of  a  special  laveur,  although  an  ordinary  irrigating  apparatus  is  useful. 

During  the  entire  course  of  the  treatment  Ihe  lids  should  be  kept  greased 
with  pure  vaseline,  which  should  also  be  freely  introduced  within  the  con- 
junctival cul-de-sac. 

Depletion  is  sometimes  practised,  but,  unless  the  indications  for  canthotomy 
are  present,  its  value  is  questionable.     The  same  may  be  said  of  the  practice. 


240  GENITO-URINARY  SURGERY 

once  common,  of  beginning  the  treatment  by  bringing  the  patients  under  the 
influence  of  mercury.  Usually  they  are  debilitated,  and  supporting  treatment — 
quinine,  iron,  strychnine,  and  milk  punch — is  essential.  If  the  pain  is  severe, 
there  is  no  objection  to  the  use  of  morphine  or  opium,  the  latter  drug  having 
a  good  influence  on  the  sloughing  process  in  the  cornea. 

Metastatic  Gonorrhceal  Ophthalmia. — This  disease  is  occasionally  seen 
during  gonorrhoea,  and  does  not  depend  upon  the  introduction  into  the  eye  of 
infecting  material  from  the  urethra.  It  is  apt  to  occur  in  patients  who  suffer 
from  articular  complications.  It  is  bilateral,  mild  in  character,  and  resembles 
a  moderate  catarrhal  conjunctivitis.    Sometimes  iritis  complicates  it. 

■    The  treatment  is  that  of  conjunctivitis  or  iritis  from  other  causes.     Bac- 
terins  are  sometimes  serviceable. 

Virulent   Gonorrhceal   Conjunctivitis.  Rheumatic  Gonorrhceal  Ophthalmia. 

A  rare  but  serious  affection.  More  common  but  less  serious. 

Essential   cause   is   inoculation   with  gon-  Probably  the  causative  agent  comes  from 

orrhoeal    pus    from    without ;    violently  within    through    the    blood.      Probably 

contagious ;  gonococci  abundant  in  pus.  metastatic ;  gonococci  not  found  except 

Not   dependent   on   or   necessarily   coinci-  in  the  later  stages  and  then  with  diffi- 
dent with  rheumatoid  affections.  culty. 

May  affect  subjects  not  afflicted  with  ure-  Is  coincident  with  gonorrhceal  arthritis, 
thritis,   as   in  infants    (ophthalmia  neo- 
natorum). 

Usually  affects  only  one  eye,  but  may  be  Occurs  only  in  patients  with  gonorrhoea! 

transferred  to  the  other.           '  urethritis. 

The   conjunctiva   is   always   the   structure       Commonly  the  disease  is  bilateral  in  the 
primarily  involved.  beginning;    or    rarely    may   move    from 

one  eye  to  the  other. 
Disease   usually   starts   in   the   iris    mem- 
brane  of   Descemet   and   may  later   in- 
volve the  oculo-palpebral  conjunctiva. 
ISIo  tendency  to  recur  in  subsequent  ure-      Marked  tendency  to  recur. 

thritis. 
Prognosis  extremely  grave;  often  loss  of      Prognosis  favorable;  no  loss  of  eyesight. 

the  eyesight. 
Treatment  must  be  specific  and  active.  Treatment  need  be  only  symptomatic. 

The  epidemic  conjunctivitis  due  to  the  Koch- Weeks  bacillus  or  to  the  pneu- 
mococcus  affects  both  eyes  with  but  moderate  severity,  is  usually  observed  in 
more  than  one  member  of  a  family  and  fails  to  show  gonococci  in  the  moderate 
■discharge. 

Gonorrhoeal  Rheumatism,  or  Metastatic  Gonorrhoea 

Gonorrhceal  rheumatism,  a  local  expression  of  gonococcic  septicaemia,  com- 
monly affects  the  joints.  It  may,  however,  involve  the  bones,  tendons,  nerves, 
bursae,  pericardium,  endocardium,  and  meninges  of  the  cord.  It  is  due  to 
systemic  poisoning  by  the  specific  microorganisms  or  by  the  ordinary  bacteria 
of  suppuration  and  the  toxalbumens  formed  by  these  germs.  When  it  is  caused 
by  gonococci  carried  from  the  urethra  or  from  a  wound  into  the  circulation 
and  lodged  at  remote  points,  the  inflammation  is  fibrous  and  adhesive  in  type. 

Finger  in  a  fatal  case  of  gonorrhoeal  rheumatism  discovered  gonococci  in  the 


COMPLICATIONS  OF  GONORRHCEA 


241 


vegetations  of  the  endocarditis.    There  was  also  myocarditis,  due  to  the  presence 
of  these  germs. 

When  there  is  free  pus-formation  the  ordinary  pyogenic  microbes  are  found. 

The  disease  may  begin  before  the  third  week  of  the  urethritis,  though  it 
commonly  develops   much  later. 

In  the  order  of  frequency  the  knee,  ankle,  wrist,  and  elbow  are  the  joints 
commonly  involved.  Usually  more  than  one  joint  is  inflamed  at  a  time,  though 
in  about  one-third  of  all  cases  the  disease  is  monarticular. 

It  develops  in  about  two  per  cent,  of  all  cases  of  urethritis,  and  is  far  more 
frequently  olDserved  in  men  than  in  women. .  It  may  complicate  gonorrhoea  of 
any  mucous  surface, — the  conjunctiva,  for  instance. 

Arthritis  is  the  commonest  manifestation  of  gonorrhoeal  rheumatism.  It 
may  be  ushered  in  by  general  rheumatic  pains,  but  more  commonly  is  char- 
acterized by  rather  sudden  swelling,  pain,  tenderness,  and  redness  of  the  af- 
fected articulation.  There  is  synovial  ,^^  ^^ 
exudation,  with  fixation  of  the  joint  in 
the  position  which  most  relaxes  its  sy- 
novial investment.  There  is  moderate 
fever.    Pain  is  severe. 

These  acute  symptoms  usually  last 
for  several  days.  The  fever  then  sub- 
sides, and  complete  resolution  may 
quickly  follow,  or  the  patient  may  suf- 
fer for  weeks  or  months  from  swelling, 
tenderness,  and  harassing  pain,  subject 
to  occasional  exacerbations  in  accord- 
ance with  the  condition  of  the  urethra. 
Such  joints  commonly  remain  partly  or 
completely  stiff.  Rarely  suppuration 
takes  place,  characterized  by  constitu- 
tional and  local  symptoms  of  pus- forma-  ■  m  -4'^^^^  I 
tion,  resulting,  if  the  patient  recovers,    -                        .    .  nJ^-^dL^mm.  ^.......^ 

in   ankylosis  of   the  joint.  ^'^-     123.-Subacute  gonorrhceal  arthritis  of  knee. 

Sometimes  the  chronic  inflammation  produces  a  condition  of  hydrarthrosis, 
attended  ^vith  limitation  of  motion,  but  otherwise  causing  little  pain  and  but 
slight  disability.  The  effusion  usually  undergoes  absorption.  Occasionally  it 
lasts  for  weeks  or  months,  causes  stretching  of  the  ligaments,  and  finally  preter- 
natural mobility  and  profound  alteration  in  the  joint. 

Symptoms. — There  is  absolutely  no  characteristic  feature  of  the  joint 
affection  which  will  enable  the  surgeon,  from  a  local  examination,  to  distinguish 
gonorrhoeal  inflammation  from  that  caused  by  other  infections.  In  making  a 
diagnosis,  however,  the  following  points  should  be  borne  in  mind.  In  gonor- 
rhoeal "  rheumatism  "  there  is  a  preceding  history  of  urethritis,  and  the  severity 
of  the  rheumatic  attack  varies  in  proportion  to  the  exacerbations  and  remissions 
of  the  urethral  inflammation.  The  disease  rarely  pursues  the  acute  course 
observed  in  ordinary  "  rheumatism,"  but  rather  has  a  tendency  to  become 
chronic,  and  after  it  has  once  occurred  is  prone  to  relapse  in  case  of  new 
infection  of  the  urethra  (Fig.  123). 
16 


242  GENITO-URINARY  SURGERY 

The  distinction  between  gonorrhoea!  arthritis  and  that  due  to  "  rheumatism  " 
is  exceedingly  difficult  to  make.  In  the  former  case,  however,  but  few  joints 
are  involved  at  one  time,  rarely  more  than  two  or  three,  and  in  these  the 
inflammation  does  not  appear  synchronously,  but  one  inflames  after  the  other. 
The  involvement  of  more  than  one  joint  is  the  rule  in  gonorrhoea  rather  than 
the  exception.  The  fever  is  never  very  high,  except  in  the  rare  cases  when 
suppuration  occurs,  nor  is  sweating  so  pronounced  a  symptom  as  in  rheumatism. 
The  gonococcus  complement-fixation  test  is  positive. 

Occasionally  the  gonorrhoeal  "  rheumatism  "  takes  the  form  of  periarthritis 
The  symptoms  are  much  the  same  as  those  of  arthritis,  except  that  there  is  no 
exudation  into  the  joint-cavity,  and  the  redness,  oedema,  pain,  and  tenderness  are 
more  marked.    It  commonly  terminates  in  resolution,  but  may  cause  ankylosis. 

Prognosis. — In  the  great  majority  of  cases  permanent  damage  does  not 
result  from  the  disease,  though  in  the  more  severe  infections,  and  when  the 
disease  is  treated  improperly,  stiffness  or  even  ankylosis  may  result. 

Treatment. — For  the  satisfactory  treatment  of  gonorrhoeal  arthritis  it  is 
necessary  that  not  only  the  disease  in  the  joint  be  cured,  but  that  the  focus  of 
infection  be  eradicated,  that  a  recurrence  of  the  disease  in  the  same  joint,  or 
the  infection  of  additional  articulations  may  be  avoided.  The  eradication  of 
the  focus  of  infection  may  imply  prostatic  or  seminal  vesicular  drainage,  the 
cutting  of  a  stricture,  or  a  more  conservative  treatment. 

The  treatment  of  the  joint  itself  may  be  divided  conveniently  into  expectant 
or  nonoperative  treatment,  surgical  treatment,  and  physiological  or  biological 
therapy,  including,  in  the  last.  Bier's  hypersemic  treatment,  and  serum  and 
bacterin  therapy. 

Expectant  Treatment. — This  consists  in  putting  the  part  at  rest,  by  splinting 
and  traction  (confining  the  patient  to  bed  where  needful),  protecting  it  from 
cold,  and  applying  various  lotions  and  ointments.  Of  the  former  the  most  useful, 
provided  surface  chilling  is  not  distressing,  are  a  saturated  solution  of  magnesium 
sulphate  and  equal  parts  alcohol  and  lead  water;  of  the  latter,  one  composed  of 
equal  parts  ung.  hydrarg.,  ung.  belladonna,  ung.  iodi  comp.,  and  petrolatum  is 
serviceable.  Baking  at  a  temperature  of  250  to  300°  F.  for  fifteen  to  twenty- 
five  minutes  once  a  day  or  once  in  two  days  is  helpful  in  subacute  and  chronic 
cases.  Internal  medication  is  useless,  with  the  possible  exception  of  calcium 
sulphide,  by  the  use  of  which  in  enormous  doses,  sufficient  to  impart  its  odor 
to  the  breath,  good  results  are  reported  to  have  been  secured. 

Surgical  Treatment. — Aspiration  is  the  simplest  of  these  procedures,  and  is 
indicated  when  there  is  a  considerable  amount  of  fluid  in  the  joint.  The  skin 
should  be  pierced  with  a  tenotome  before  inserting  the  needle,  in  order  to  avoid 
infection.  The  injection  of  5  to  20  c.c.  of  2  per  cent.  liq.  formaldehyde  in 
glycerine  after  aspiration  of  the  contained  fluid,  as  recommended  by  Murphy, 
with  the  application  of  extension  in  order  to  keep  the  articulating  surfaces 
separated,  gives  good  results,  but  causes  great  pain. 

Arthrotomy,  with  irrigation  of  the  joint  through  the  incision  with  carbolic 
acid  (1:  500  to  1:  100)  or  similar  lotion,  has  given  good  results,  but  on  account 
of  the  danger  of  engrafting  an  additional  infection  should  be  reserved  for  cases 
of  the  greatest  severity.     Even  when  the  synovia  is  purulent,  the  first  time 


COMPLICATIONS  OF  GONORRHCEA 


243 


arthrotomy  is  performed  on  a  joint  the  wound  should  be  closed  without  drainage. 

Physiological  and  Biological  Therapy. — Bier's  Hyperccmia. — This  is  applied 
by  wrapping  a  light  rubber  bandage  about  the  limb  sufficiently  tight  to  lessen 
the  flow  of  venous  blood  without  interfering  with  the  arterial  circulation,  thereby 
causing  the  tissues  to  contain  an  increased  supply  of  blood  (Fig.  124).  The 
bandage  should  not  be  tight  enough  to  cause  pain,  mottling  or  coldness  of  the 
part,  and  should  be  worn  for  long  periods  of  time,  ten  hours  twice  a  day,  with 
intervals  of  two  hours  between  the  applications;  or  shorter  applications  may 
be  used  if  deemed  advisable.  In  addition  to  the  benefit  derived  from  the 
increased  supply  of  blood,  some  degree  of  auto-vaccination  is  probably  produced 
by  the  hyperaemia. 

Serum  Therapy. — The  administration  of  antigonococcic  serum,  prepared 
after  the  method  devised  by  Rogers  and  Torrey,  is  useful,  particularly  in  the 

more  acute  stages  of  the  disease,    ,  -  .„. ^-,,. . 

though   in   many  cases  the   more  \ 

chronic  forms  also  react  well.  The 

serum  is  injected  in  doses  of  2  c.c.  .      '  * 

every  other  day,  or  at  longer  in- 
tervals should  reactions  occur.  In 
the  absence  of  either  reactions  or 
improvement,  after  three  or  four 
doses,  the  amount  injected  may  be 
doubled  or  tripled.  If  improve- 
ment is  not  secured  with  four  to 
six  doses  the  method  should  be 
abandoned  as  useless. 

Bacterin  Therapy.  —  This  is 
probably  the  most  generally  ap- 
plicable method-  of  treatment.  It 
may  be  used  in  either  the  acute 
or  chronic  stages,  though  the 
most  brilliant  cures  have  been  effected  in  the  latter.  While  some  men  have 
obtained  the  best  results  by  the  use  of  enormous  doses,  five  hundred  million  to 
a  billion,  it  is  better  to  start  the  treatment  with  small  doses,  20  to  50  million, 
gradually  increasing  the  dose  as  indicated  in  the  chapter  on  Bacterin  Therapy. 

Exostoses. — Baer  calls  atention  to  an  affection  characterized  by  a  painful 
bony  outgrowth  from  the  tubercle  of  the  os  calcis  (Fig.  125),  lying  just  in  front 
of  the  attachment  to  the  plantar  fascia.  Pain,  the  chief  symptom,  is  referred 
directly  to  the  attachment  of  the  plantar  fascia  with  the  os  calcis,  and  is  elicited 
only  by  pressure.  The  patient  usually  walks  on  the  ball  of  the  foot.  The 
affection  appears  in  young  males  in  the  first  year  of  a  chronic  gonorrhoea.  It  is 
bilateral.  The  diagnosis  is  based  on  the  radiogram.  Treatment  is  by  operation 
and  removal  of  the  bony  outgrowth  and  is  entirely  successful.  This  condition 
of  painful  overgrowth  has  been  encountered  in  men  who  have  never  had  a 
urethral  infection. 

Tenosynovitis. — This  affection  develops  usually  after  the  acute  stage  of 
gonorrhoea  has  passed.     The  involved  tendon  exhibits  over  its  course  tenderness, 


Fig.  124.- 


hyperemic  treatment  of  elbow  and  wrist. 


244 


GEXITO-URINARY  SURGERY 


redness,  oedematous  swelling,  and  crepitation  or  distinct  fluctuation.  The  ten- 
dons most  commonly  involved  are  the  extensors  of  the  fingers,  the  flexor  of  the 
thumb,  and  the  tendons  of  the  toes. 

Pericarditis,  Endocarditis,  Pleuritis,  and  jVIeningitis  are  rare  compli- 
cations of  gonorrhoea.  Their  treatment  is  that  of  similar,  conditions  of  other 
etiolog}'.  -n-ith  the  addition  of  serum  and  bacterins,  which  are  useful  in  some 
cases,  and  should  be  given  a  cautious  trial. 

Phlebitis. — Heller  notes  that  gonorrhoea!  phlebitis  is  commonest  in  men 
in  the  fourth  or  fifth  week  of  a  first  attack.    The  internal  saphenous  vein  is 


Fig.  125. — Gonorrhceal  exostosis  of  the  os  calcis. 

most  frequently  involved:  next  the  common  femoral,  the  superficial  veins  of 
the  abdominal  parietes,  the  veins  of  the  corpora  cavernosa,  sometimes  those 
of  the  arm.  There  are  acute  pain  and  fever.  Until  the  external  veins  are 
involved,  forming  indurated  cords,  the  diagnosis  cannot  be  made.  Two  out 
of  the  twenty-six  cases  died, — one  of  embolus  and  one  of  sepsis.  One  required 
amputation  at  the  thigh.  The  treatment  is  by  rest,  evaporating  lotions,  and 
later  by  absorbents. 

Diagnosis. — The  gonococcic  nature  of  such  affections  as  pericarditis,  pleu- 
ritis, and  meningitis  can  be  determined  only  by  the  discovery  of  these  organisms 
in  the  blood,  even  though  a  gonococcal  urethritis  be  present.  This  requires  the 
removal  by  venopuncture  of  about  twent}'  cubic  centimetres  of  blood  and  its 
immediate  culture,  since  the  diplococcus  intracellularis  meningitidis,  the  micro- 
coccus catarrhalis,  and  some  others  decolorize  bv  the  Gram  method. 


CHAPTER  XIII 

STRICTURE  OF  THE  URETHRA 

A  STRICTURE  is  a  temporary  or  permanent  narrowing  of  the  urethral  canal, 
caused  by  muscular  spasm  or  by  organic  changes  in  the  tissues  which  make  up 
its  walls. 

Strictures  may  be  congenital  or  acquired. 

Congenital  stricture  is  extremely  rare,  except  at  the  meatus  or  in  its  imme- 
diate vicinity.  Even  these  narrowings  are  often  the  result  of  infantile  balano- 
posthisis,  and  thus  not  really  congenital.  A  narrowing  of  the  meatus,  reducing 
it  almost  to  pin-point  size,  may  exist  from  birth  without  giving  rise  to  appre- 
ciable difficulty,  and,  unless  some  urinary  symptoms  appear,  may  escape  notice; 
the  more  severe  grades  should  be  treated  by  meatotomy. 

The  normal  narrowing  at  the  meatus  is  of  physiological  importance  in  favor- 
ing the  projection  of  a  strong,  smooth  stream  of  urine  and  the  vigorous  ejacula- 
tion of  the  sperm:  hence  free  division  of  the  meatus  should'  not  be  advised 
on  insufficient  grounds.  Not  infrequently  the  operation  may  leave  the  patient 
with  an  artificial  balanohypospadia  and  diminished  projectile  force.  Congenital 
strictures  should,  however,  be  operated  upon  promptly  when  urinary  symptoms 
arise  which  reasonably  can  be  traced  to  them,  or  when  they  interfere  with  the 
proper  treatment  of  more  deeply  seated  morbid  conditions  of  the  urethra  or  of 
the  bladder. 

Acquired  stricture  is  classified  in  accordance  with  its  pathology  under  these 
general  headings: 

1.  Inflammatory, 

2.  Spasmodic. 

3.  Organic:  (a)  of  large  calibre ;  (b)  of  small  calibre. 

1.  Inflammatory  stricture  is  due  to  an  acute  catarrhal  inflammation 
with  recent  soft  exudate,  causing  swelling  of  the  mucous  membrane  and  encroach- 
ment on  the  urethral  calibre.  It  is  of  short  duration,  and  never  causes  retention, 
except  when  complicated  by  muscular  spasm.  It  is  often  the  first  step  in  the 
formation  of  organic  stricture. 

Treatment . — The  treatment  is  that  appropriate  to  acute  anterior  urethritis. 
The  term  inflammatory  stricture  is  misleading,  since  some  authors  thus  designate 
true  organic  strictures, — i.e.,  those  which  ultimately  result  from  chronic  inflam- 
mation with  formation  of  fibrous  tissue. 

2.  Spasmodic  stricture  is  a  temporary  narrowing  or  obliteration  of  the 
urethra,  due  to  contraction  of  the  involuntary  or  voluntary  muscles  investing  it. 
This  contraction  is  either  reflex  or  psychical  in  its  origin ;  the  compressor  urethrse 
is  usually  the  muscle  at  fault. 

Reflex  muscular  spasm  commonly  depends  on  irritation  transmitted  from 
some  hypersemic  point  of  the  urethra,  as  from  the  actively  inflamed  mucous 
membrane  of  the  posterior  urethra,  or  from  a  patch  of  granular  urethritis  sit- 
uated in  or  near  the  bulb.     More  rarely  it  may  arise  from  irritation  at  a  greater 

245 


246  GENITO-URINARY  SURGERY 

distance,  as  from  fissure  of  the  anus,  hemorrhoids,  worms,  cancer  of  the  rectum, 
etc. 

Among  the  causes  of  spasm  may  be  mentioned  strongly  acid  or  irritating 
conditions  of  the  urine,  as  in  cantharidal  poisoning  or  the  uric  acid  diathesis,  and 
urethral  hypersesthesia  from  sexual  excess.  Organic  stricture  is  the  usual  pre- 
disposing factor  in  the  development  of  the  symptoms  of  spasmodic  stricture. 

The  retention  of  urine  incident  to  overdistention  of  the  bladder,  or  acute 
fevers,  or  surgical  operations,  especially  those  upon  the  anus  and  the  rectum, 
is  probably  at  times  the  result  of  vesical  inhibition,  although  it  is  usually 
attributed  to  urethral  spasm. 

Numerous  cases  have  been  reported  in  which  a  more  or  less  persistent  spasm 
has  been  attributed  to  a  small  meatus,  since  cure  followed  meatotomy;  but  it 
must  be  remembered  that  spasmodic  stricture  is  particularly  apt  to  occur  in 
nervous,  excitable,  irritable  young  men,  allied  in  type  to  hysterical  women, 
and  that  in  such  patients  any  marked  mental  impression  may  cause  a  dis- 
appearance of  existing  symptoms.  If  the  meatus  is  too  small  to  admit  a  good- 
sized  sound,  in  the  presence  of  otherwise  inexplicable  urinary  symptoms  a  cutting 
operation  is  clearly  indicated. 

Spasmodic  ^stricture  due  to  psychical  cause  is  instanced  by  the  inhibiting 
effect  which  shame  or  even  a  sense  of  hurry  exerts  over  the  function  of  mictu- 
rition. 

Diagnosis. — The  diagnosis  of  spasmodic  stricture  is  founded  upon  the  sudden 
onset  of  either  dysuria  or  retention  of  urine  without  inflammatory  symptoms 
and  without  preceding  symptoms  of  urethral  obstruction.  Sometimes  the  stream 
is  irregularly  interrupted,  a  condition  designated  as  stuttering  micturition.  The 
introduction  of  a  full-sized  metal  instrument  may  be  resisted  at  first,  but  on 
gentle  continued  pressure  the  contracted  muscles  may  be  felt  to  yield  and  the 
instrument  readily  slips  into  the  bladder. 

Treatment. — The  treatment  of  spasmodic  stricture  varies  in  accordance  with 
the  cause.  When  symptoms  recur,  careful  search  always  should  be  made  for 
organic  stricture;  this,  if  cured,  will  be  followed  by  disappearance  of  the  tendency 
to  spasm.  Every  pathological  condition  about  the  genitalia  or  rectum  should 
be  corrected,  and  in  the  absence  of  contra-indications  full-sized  sounds  should 
be  passed  at  regular  intervals. 

When  spasmodic  stricture  is  complicated  by  retention,  the  patient  should  be 
put  in  a  hot  general  bath  (106°  to  110°  F.),  and  directed  to  urinate  while 
therein.  A  hot  sitz-bath  is  equally  efficacious,  but  should  be  continued  not  over 
fifteen  minutes.  If  at  the  end  of  this  time  the  bladder  has  not  been  emptied, 
the  patient  should  be  thoroughly  dried,  put  to  bed,  and  given  suppositories  con- 
taining opium  and  belladonna,  or  hypodermic  injections  of  morphine.  These 
palliative  measures  should,  however,  never  be  persisted  in  when  the  bladder  is 
greatly  distended — i.e.,  is  readily  perceptible  on  suprapubic  percussion.  The 
possible  remote  effects  of  overdistention  of  the  bladder  are  far  more  to  be 
dreaded  than  the  slight  discomfort  attendant  on  the  passage  of  an  instrument: 
hence  if  the  distention  is  great  and  the  hot  bath  fails  to  give  relief,  catheteriza- 
tion should  be  practised  at  once.  A  soft  rubber  or  an  English  catheter  should 
be  used  first;  if  these  fail,  a  metal  instrument  should  be  introduced.    It  must 


I 


STRICTURE  OF  THE  URETHRA  247 

be  borne  in  mind  that  under  these  circumstances  the  bladder  is  peculiarly  liable 
to  become  infected;  therefore  the  catheterization  must  be  practised  with  the 
observance  of  all  the  antiseptic  precautions  customary  in  major  operations. 
The  surgeon's  hands  must  be  thoroughly  cleansed,  the  instrument  sterile,  the 
glans  and  meatus  disinfected,  and  the  anterior  urethra  previously  flushed  out 
with  an  antiseptic  solution. 

3.  Organic  Stricture. — This,  in  the  vast  majority  of  cases,  is  due  to  a 
preceding  urethritis  or  to  traumatism,  though  a  chancroid,  chancre,  or  ulcer  due 
to  lodgement  of  a  foreign  body  may  subsequently  be  followed  by  cicatricial 
narrowing.     Gonorrhoeal  urethritis  is  by  far  the  most  common  cause. 

Organic  stricture  may  occur  in  persons  of  any  age,  but  is  most  frequent 
between  the  ages  of  twenty  and  forty-five.  Women  are  not  entirely  exempt. 
Gonorrhoeal  stricture  is  said  to  occur  less  frequently  in  negroes  than  in  white 
men.  The  longer  the  duration  of  the  attack  of  gonorrhoea  the  more  liable  is 
the  patient  to  have  a  stricture.  The  intensity  of  the  attack  is  also  of  some 
importance  in  this  regard.  The  supposed  development  of  stricture  because  of 
too  rapid  cure  of  gonorrhoea  is  a  popular  myth;  the  more  speedy  the  cure  the 
less  likely  are  strictures  to  form,  nor  have  strong  irritating  injections  any 
effect  on  the  production  of  stricture  unless  they  cause  complications,  such  as 
abscess,  or  prolong  the  inflammation. 

The  rapidity  of  stricture  development  is  dependent  upon  the  nature  of  the 
original  lesion.  In  case  of  rupture  of  the  urethra  narrowing  of  the  lumen  of 
this  canal  begins  from  the  time  the  wound  cicatrizes;  that  is,  usually  within  a 
few  weeks.  In  the  case  of  gonorrhoea,  however,  the  process  is  much  slower.  The 
infiltration  caused  by  this  disease,  unless  complicated  by  periurethral  abscess, 
is  essentially  chronic.  It  is  always  a  matter  of  months,  and  usually  of  years, 
before  this  infiltration  undergoes  sufficient  organization  to  encroach  seriously 
upon  the  calibre  of  the  urethra.  It  may  be  said  in  general  terms  that  a  stricture 
rarely  develops  within  one  year  of  the  beginning  of  an  attack  of  gonorrhoea. 
Guyon  holds  that  the  greatest  number  of  strictures  occur  four  to  ten  years  from 
the  beginning  of  the  original  urethritis. 

Prolonged  erection,  excessive  coitus,  and  masturbation  have  been  regarded 
as  competent  causes  of  stricture,  especially  by  the  ardent  believers  in  strictures 
of  large  calibre,  who  find  this  lesion  in  nearly  every  urethra,  often  wdthout  a 
history  of  gonorrhoea  or  of  any  of  the  sources  of  irritation  previously  mentioned. 
Theoretically  stricture  is  possible  from  such  causes,  but  practically  it  is  of 
the  greatest  rarity. 

Traumatic  stricture  follows  such  wounds  and  contusions  of  the  perineum  as 
have  caused  partial  or  complete  laceration  of  the  urethra.  Kicks  in  the  peri- 
neum, falls  astride  of  a  resistant  body,  and  fractures  of  the  pelvis  often  cause 
such  ruptures.  "  Fracture  of  the  penis," — that  is,  a  sudden  twist  or  bend  of 
the  erect  penis,  which  causes  subcutaneous  rupture  of  the  erectile  tissue; 
"  breaking  a  chordee," — i.e.,  violently  straightening  the  curve  incident  to  the 
inflammatory  infiltration  of  the  urethra  and  periurethral  tissues;  injuries  due 
to  the  rough  and  clumsy  use  of  urethral  instruments;  surgical  treatment  of 
previously  existing  strictures,  such  as  incision,  excision,  cauterization,  and  elec- 
trolysis,— all  these  causes  may  produce  traumatic  strictures. 


248 


GEXITO-URINARY  SURGERY 


-B 


CLIXICAL  FORMS  OF  STRICTURE 

The  strictured  part  of  the  urethra  varies  greatly  in  extent,  from  a  mere  dia- 
phragm-like band,  linear  stricture  (Fig.  126),  to  one  slightly  broader,  annular 
stricture  (Fig.  127),  and  from  that  to  a  contraction  which  may  involve  two  or 
three  inches  of  the  canal,  changing  it  into  a  devious,  irregular  channel,  tortuous 
stricture  (Fig.  128). 

Strictures  may  also  be  classified  as:  1.  Sojt  or  recent,  the  subepithelial  exu- 
date not  yet  having  become  extensively  organized  into  connective  tissue.  They 
are  of  large  calibre.  2.  Cicatricial,  characterized  by  an  ill-defined  mass  of 
fibrous  tissue  often  cartilaginous  in  consistency.  The  traumatic  strictures  are 
made  up  entirely  of  fibrous  tissue;  the  gonorrhceal  strictures  still  exhibit  traces 
of  the  original  structure  of  the  parts. 

There  is  also  a  peculiar  form  of  contrac- 
tion of  the  meatus,  which  appears  as  a  dif- 
fuse induration  of  the  mucous  membrane, 
scar-like  in  appearance  and  cartilaginous  in 
consistency;  this  extends  outward  on  the 
glans  and  for  some  distance  inward;  it  is 
apparently  a  form  of  scleroderma.  Local 
\—&  treatment  is  of  little  use,  but  there  is  often 
some  spontaneous  improvement  after  a 
\—E  considerable  lapse  of  time. 

Strictures  are  further  classified  as, — ■ 

1.  Simple, — that  is,  exhibiting  only  the 
symptoms  and  reactions  characteristic  of 
the  majority  of  strictures. 

2.  Irritable. —  Instrumentation  causes 
unusually  severe  pain,  is  sometimes  fol- 
lowed by  hemorrhage,  and  excites  undue 
local  inflammation  or  occasions  urethral 
fever. 

3.  Resilient,  Contractile,  or  Recurring. 
■ — The  stricture  if  untreated  steadily  be- 
comes tighter.     Even  if  it  can  be  dilated,, 

it  again  contracts  so  rapidly  that  this  method  of  treatment  is  without  benefit. 

In  accordance  with  the  extent  to  which  they  narrow  the  urethra,  strictures 
are  either  of  large  calibre  or  of  small  calibre. 

The  terms  permeable  and  impermeable  indicate  whether  or  not  an  instru- 
ment can  be  passed  through  the  narrowing. 

Every  stricture  following  a  urethritis  must  at  some  time  have  been  a  stricture 
of  large  calibre,  but  just  when  such  a  stricture  becomes  a  pathological  factor 
and  is  able  to  give  rise  to  symptoms  is  an  unsettled  point.  There  is  no  fixed 
calibre  of  the  urethra,  and  the  size  of  the  meatus  is  not  a  rehable  index  as  to 
the  diameter  of  the  canal  behind  it.  The  circumference  of  the  flaccid  penis 
affords  the  best  indication  as  to  the  size  of  the  urethra,  the  calibre  of  this  canal 


ElG.  126. — Linear  strictures.  A,  glans; 
B,  glandular  urethra;  C,  spongy  body;  D, 
urethra  dilated  behind  the  stricture;  E.  linear 
stricture;  G,  linear  stricture  less  developed; 
a,  cavernous  body.      (Voillemier.) 


STRICTURE  OF  THE  URETHRA 


249 


increasing  in  proportion  to   the  growth  of   the  penis;    but   the   ratio  is  only 
approximate  and  is  liable  to  variation. 

The  increased  friction  and  resistance  resulting  from  even  a  slight  fibrous 
periurethral  deposit  may  disturb  the  equilibrium  which  has  been  established 
and  maintained  between  the  usual   efforts  and  power  of  the  bladder  as  an 


Linear 


"  Annular 


Tortuous 


Fig.  127. — Strictures  of  the  urethra.  Illustrations  of  both  the 
annular  and  tortuous  types  of  the  disease;  so  tight  had  the  tortuous 
or  posterior  of  the  two  become  that  fistulae  formed.  (Laboratory 
of  Pathology,  University  of  Pennsylvania.) 


Fig.  12s. — Diagram- 
matic representation  of 
the  three  common 
varieties  of  urethral 
stricture. 


expulsive  organ  and  a  certain  average  of  resistance  which  must  be  overcome 
before  it  can  empty  itself.  As  a  result  the  bladder  becomes  irritable,  and  is 
often  rendered  still  more  so  by  inflammation  of  the  posterior  urethra  incident 
to  backward  extension  of  the  catarrhal  process  usually  active  at  the  seat  of 
narrowing.  Thus  is  caused  one  of  the  most  constant  of  the  stricture  symptoms, — 
i.e.,  frequent  urination. 

The  imperfect  closure  of  the  tube  occasioned  by  the  inflammatory  infiltrate, 


250  GENITO-URINARY  SURGERY 

which  prevents  the  urethral  walls  from  being  pressed  tightly  to  each  other  by 
their  investing  layer  of  involuntary  muscle,  causes  imperfect  expulsion  of  the 
last  drops  of  urine,  and  produces  another  characteristic  symptom, — dribbling 
at  the  end  of  micturition. 

The  retention  and  decomposition  of  these  last  few  drops,  together  with  the 
abnormal  friction  between  the  stream  of  urine  and  the  urethral  walls  at  the 
site  of  narrowing,  cause  a  subacute  inflammation  of  the  mucous  membrane, 
accompanied  by  a  catarrhal  or  mucopurulent  gleety  discharge. 

Pain  is  developed  in  the  lumbar  and  hypogastric  region  by  reflex  irritation 
transmitted  from  the  area  of  inflammation  and  from  the  irritated  bladder. 

Where  the  urethral  calibre  is  markedly  diminished,  the  relation  between 
causes  and  effects  is,  in  the  main,  as  just  stated.  As  to  how  far  the  narrowing 
must  go  before  such  symptoms  are  excited,  no  dogmatic  assertion  can  be  made. 
Otis  has  promulgated  a  scale  of  relation  between  the  calibre  of  the  urethra  and 
the  circumference  of  the  flaccid  penis,  any  departure  from  which  he  regards  as 
an  evidence  of  the  existence  of  stricture.  This  scale  doubtless  represents  accu- 
rately the  distensibility  of  the  male  urethra,  but  it  does  not  represent  what  can 
fairly  be  called  its  normal  calibre.  The  variation  in  size  and  dilatability  of  the 
different  parts  of  the  urethra  has  long  since  been  clearly  demonstrated  by 
Delpet,  Guyon,  Sappey,  and  many  others. 

Otis,  however,  in  effect  assumes  that  the  urethra  should  be  a  tube  of  uniform 
calibre,  at  least  anterior  to  the  triangular  ligament,  and  the  instrument  which 
he  has  devised, — the  urethrometer, — when  used  under  the  guidance  of  his  tables, 
will  detect  apparent  strictures  in  the  majority  of  normal  urethrae.  His  teachings 
have,  nevertheless,  been  of  great  value,  since  they  have  demonstrated  the  dis- 
tensibility of  the  normal  urethra,  have  clearly  shown  the  full  pathological 
effect  of  true  stricture,  however  slight,  and  have  rendered  urethral  surgery 
more  exact. 

A  purely  arbitrary  standard  has  been  established  for  convenience  in  classify- 
ing organic  strictures  in  accordance  with  the  degree  of  narrowing.  This  is 
expressed  in  the  following  definitions: 

Strictures  of  large  calibre  are  those  through  which  a  sound  or  bougie  larger 
than  No.  15  (F.)  can  be  passed. 

Strictures  of  small  calibre  are  those  through  which  instruments  larger  than 
No.  15  (F.)  cannot  be  passed. 

LOCATION  OF  STRICTURE 

In  the  large  majority  of  cases  gonorrhceal  stricture  is  situated  in  the  bulbo- 
membranous  portion  of  the  urethra.  The  next  most  frequent  seat  is  the  first 
two  and  a  half  inches  of  the  urethra,  and  the  least  frequent  seat  is  the  middle 
of  the  spongy  urethra.  Stricture  of  the  prostatic  region  is  extremely  rare.  The 
occurrence  of  stricture  in  these  regions  is  due  to  the  facts  that  they  are  excep- 
tionally vascular,  and,  with  the  exception  of  the  membranous  urethra,  are  rich 
in  glands  and  follicles,  and  that  chronic  urethritis  is  apt  to  become  localized  at 
these  points. 

The  differences  of  opinion  in  regard  to  the  localization  of  stricture  are  due 
to  the  different  standpoints  from  which  the  subject  is  regarded.     Those  who 


STRICTURE  OF  THE  URETHRA 


251 


demand  evidence  of  some  organic  change  before  admitting  the  existence  of 
stricture,  and  who  base  their  views  on  the  examinations  of  specimens  in  museums, 
differ  greatly  in  their  conclusions  from  those  who  depend  upon  the  findings  of 
the  urethrometer,  and  who  believe  in  an  almost  unvarying  relation  between  the 
calibre  of  the  urethra  and  the  size  of  the  penis.  In  three  hundred  and  twenty- 
one  specimens  examined  by  Sir  Henry  Thompson  the  stricture  in  two  hundred 
and  sixteen,  or  sixty-seven  per  cent.,  was  found  in  the  bulbomembranous  region; 
in  fifty-four,  or  seventeen  per  cent.,  within  two  and  a  half  inches  of  the  meatus; 


Fig.  129. — Traumatic  stricture.  4,  bas-fond  of  bladder;  B, 
ecchymosis  of  the  mucous  membrane  of  the  vebical  neck,  C,  pro- 
static urethra;  D,  verumontanum,  much  deformed;  E,  lacunae;  F, 
position  of  greatest  narrowing;  mucous  membrane  transformed  to 
a  thin  layer  of  flat  epithelial  cells;  F,  small  diverticula  in  the  fi- 
brous tissue;  G,  cicatricial  tissue;  H,  small  round  cavity;  K,  spongy 
tissue  completely  destroyed;  K',  mucous  membrane  in  front  of  the 
stricture,  thin  and  rugous;  L,  spongy  body;  M,  anterior  urethra. 
(VoUemier.) 

and  in  fifty-one,  or  only  sixteen  per  cent.,  in  the  intermediate  spongy  portion. 
Otis  describes  two  hundred  and  fifty-eight  strictures  under  his  care  as  situated, 
one  hundred  and  fifteen,  or  forty-four  and  one-half  per  cent.,  in  the  first  inch 
and  a  quarter  of  the  urethra;  one  hundred  and  twenty-nine,  or  fifty  per  cent., 
from  one  and  a  quarter  to  five  and  a  quarter  inches  from  the  meatus;  and  only 
fourteen,  or  five  and  one-half  per  cent.,  from  five  and  a  half  to  seven  and  a 
quarter  inches — i.e.,  in  the  region  of  the  bulbomembranous  urethra.  It  can 
scarcely  be  doubted  that  many  of  these  "  strictures  "  were  points  of  physiologi- 
cal narrowing. 


252  GENITO-URINARY  SURGERY 

Gonorrhoeal  strictures  are  usually  multiple,  two,  three,  four,  or  even  more 
being  present. 

Traumatic  strictures  are  nearly  always  single,  and  their  situation  varies 
with  the  cause.  They  occur  in  the  mid-spongy  portion  of  the  urethra  after 
rupture  of  a  chordee;  at  the  root  of  the  penis  when  caused  by  "false  move- 
ments" in  coition;  in  the  perineobulbar  portions  of  the  urethra  when  following 
contusions  of  the  perineum;  and  in  the  membranous  portion  after  pelvic  frac- 
tures. They  are  most  frequently  found  involving  the  bulbous  urethra  (Fig. 
129). 

Strictures  following  ulceration  due  to  chancre,  chancroid,  or  the  lodge- 
ment of  foreign  .bodies  are  usually  found  at  or  near  the  meatus. 

CHANGES  IN  THE  URETHRA 

The  urethra  behind  a  stricture  undergoes  certain  progressive  changes.  It 
at  first  becomes  deeply  congested,  thinned,  and  dilated.  As  the  stricture  grows 
smaller,  alterations  in  the  mucous  membrane  become  more  and  more  marked. 
The  increasing  pressure  causes  a  corresponding  increase  in  the  pouching  or 
dilatation;  decomposition  of  the  retained  urine  sets  up  superficial  inflam- 
mation, and  erosion  of  the  mucous  surface  occurs;  ulceration  follows,  which, 
as  it  progresses,  allows  the  escape  of  urine  into  the  spongy  tissue.  Sooner 
or  later  this  causes  suppuration.  The  pus,  whether  in  minute  quantity  or 
as  the  contents  of  a  recognizable  abscess,  finds  its  way  towards  the  skin,  and 
after  its  discharge  leaves  urinary  fistulae.  These  fistulae,  when  first  formed, 
have  soft,  yielding  walls,  but  these  gradually  become  dense  and  indurated, 
undergoing  the  same  pathological  changes  as  did  the  original  strictured  region. 
Even  after  the  formation  of  a  large  fistula  progressive  contraction  still  takes 
place  at  the  posterior  surface  of  the  urethral  stricture,  since  the  fistulous  open- 
ing cannot  prevent  the  constant  contact  of  urine  with  this  portion  of  the  nar- 
rowing. As  a  result,  the  urethral  outlet  is  more  and  more  tightly  sealed,  and 
all  the  urine  is  forced  to  pass  by  the  new  way. 

Gradually,  as  the  walls  of  the  fistula  become  indurated,  its  lumen  is  nar- 
rowed by  contraction,  and  the  free  passage  of  the  urine  is  again  obstructed. 
Under  such  circumstances  it  is  extremely  rare  to  observe  any  yielding  in  the 
stricture  so  that  water  can  be  voided  per  urethram.  Ordinarily  other  abscesses 
develop  in  the  way  already  described  and  other  fistulae  are  formed. 

When  fistulae  originate  in  the  bulbar  urethra  it  is  from  the  region  of  one 
of  the  lateral  angles  of  the  canal  that  the  fistulous  tract  passes.  The  sclerosed 
bulb  is  not  traversed  directly  by  this  tract  from  above  downward.  It  winds 
laterally  round  the  half  circumference  of  the  bulb  and  opens  through  the 
skin.  Sometimes  the  bulb  is  entirely  dissected  by  two  fistulous  tracts  placed 
symmetrically  and  laterally,  uniting  near  a  single  suburethral  pouch.  These 
tracts  are  lined  with  stratified  pavement  epithelium  continuous  with  the  two 
surfaces;  hence  in  closing  them  it  is  necessary  to  extirpate  the  whole  tract. 
In  exploring  these  tracts  it  must  be  borne  in  mind  that  they  take  a  circuitous 
course,  often  entering  the  urethra  by  its  lateral  wall. 

Wassermann  and  Halle  have  shown  that  the  essential  anatomicopatho- 
logical  characteristic  of  the  lesions  of  gonorrhceal  stricture  is  their  multiplicity. 


STRICTURE  OF  THE  URETHRA  253 

as  opposed  to  the  precise  limitation  and  localization  of  traumatic  strictures. 
In  all  cases  of  old  gonorrhceal  strictures  the  urethra  exhibits  pronounced  lesions 
throughout  a  great  part  of  its  extent.  These  are  most  marked  in  the  region 
of  the  bulb.  The  calibre  of  the  urethra  is  lessened  anterior  to  the  stricture; 
behind  it  there  is  dilatation. 

The  epithelial  lining  of  the  urethra  is  constantly  altered,  thickening  and 
partial  desquamation  representing  the  commonest  lesions.  These  are  found 
in  all  portions  of  the  canal,  even  those  least  affected.  There  is  constantly 
observed  a  tendency  towards  the  transformation  of  the  cylindrical  epithelium 
to  the  stratified  pavement  form.  Commonly  there  is  a  single  basilar  layer 
of  cylindroid  cells  with  the  long  axes  perpendicular  to  the  derm.  The  middle 
layer  is  made  up  of  several  rows  of  polygonal,  usually  hexagonal,  cells;  finally, 
there  is  a  superficial  layer  continuous  with  the  middle  layer  and  made  up  of 
several  rows  of  fiat  cells  with  the  long  diameter  parallel  to  the  surface.  Some- 
times the  flattened  superficial  cell-layer  rests  directly  on  the  basilar  layer. 
All  forms  of  transition  are  observed  in  the  epithelial  cells.  The  epithelium 
may  be  thinned  and  atrophic,  or  there  may  be  proliferation,  forming  vegetat- 
ing masses  which  fill  the  urethral  calibre.  Finger  states  that  there  is  a  dis- 
tinct relation  between  the  type  of  epithelial  alteration  and  the  pathological 
changes  in  the' subjacent  tissues.  Distinctly  dermoid  and  corneous  epithehum 
(not  observed  in  the  membranous  or  prostatic  urethra)  is  usually  found  in 
the  regions  where  periurethral  sclerosis  is  most  pronounced. 

The  essential  lesion  of  stricture  is  in  the  spongy  body.  As  an  ultimate 
result  of  inflammatory  infiltration,  fibrous  tissue  is  gradually  substituted  for 
the  elastic,  extensible  vascular  tissue  of  the  spongy  urethra,  forming  a  com- 
pact inextensible  vascular  mass  showing  a  tendency  towards  retraction,  atrophy, 
and  obliteration.  Usually  the  narrowing  is  caused  by  a  fibrous  ring,  which  may 
be  regularly  disposed  or  unequally  deposited  about  the  urethra.  There  is 
no  system  in  its  distribution.  Sometimes  it  is  the  upper  segment,  some- 
times the  lower  or  lateral  segments,  that  are  most  profoundly  involved.  At  the 
strictured  point  one-half  or  two-thirds  of  the  diameter  of  the  spongy  body  is 
altered  and  obliterated. 

The  arteries  of  the  spongy  body  in  old  cases  constantly  exhibit  an  endar- 
teritis and  a  periarteritis,  sometimes  proceeding  to  complete  obliteration 
of  the  vessels.  Behind  the  stricture  the  superficial  inflammatory  lesions  are 
almost  constant,  and  it- is  here  that  embryonal  vegetations  form  by  predilec- 
tion. The  sclerosed  tissue  surrounding  the  urethra  is  not  homogeneous,  but 
contains  all  the  elements  of  normal  spongy  tissue.  It  is  the  result  of  a  species 
of  interstitial  sclerosis,  which,  though  completely  modifying  the  appearance 
and  the  properties  of  the  normal  tissue,  does  not  cause  its  total  disappear- 
ance. 

In  case  of  traumatic  stricture  the  contrary  is  the  case.  The  spongy  body 
is  entirely  replaced  in  loco  by  an  ordinary  fibrous  cicatrix. 

The  glandular  and  lacunar  lesions  of  stricture  are  constant.  Adenitis  with 
proliferation  and  epithelial  transformation,  glandular  dilatation,  and  simple 
periadenitis  are  nearly  always  found,  especially  in  the  least  altered  portions 


254  GENITO-URINARY  SURGERY 

of  the  strictured  urethra.  At  the  seat  of  stricture  the  glands  have  often  dis- 
appeared or  are  scarcely  recognizable. 

The  opening  of  the  urethra  at  the  seat  of  stricture  is  commonly  near  the 
roof  of  the  canal,  since  the  bulk  of  the  fibrous  tissue  is  usually  placed  in 
the  urethral  floor,  thus  encroaching  upon  the  lumen  of  the  canal  from  below 
upward.     The  opening  may,  however,  be  eccentric  in  any  other  direction. 

The  consistence  of  strictures  varies  with  their  age  and  with  the  amount 
of  fibrous  and  elastic  tissue  they  contain.  Their  dilatability  varies  inversely 
with  their  consistence,  as  does  their  elasticity. 

Section  of  a  stricture  of  the  annular  or  tortuous  variety  shows  a  more  or 
less  imperfect  ring  of  new  inflammatory  tissue,  whose  limits  taper  down  grad- 
ually. This  tissue  is  hard,  yellowish  white  near  the  lumen  and  darker  periph- 
erally, where  reddish  islets  are  seen,  the  result  of  hemorrhagic  infarcts, 
which  form  foci  for  new  inflammatory  changes.  Oberlander  has  shown  that 
the  inflammatory  process  practically  begins  in  the  granular  recesses.  These 
are  most  abundant  on  the  roof  of  the  urethra,  but  the  floor  presents  the 
greatest  changes,  from  the  fact  that  the  gonorrhceal  process  is  always  more 
active  there. 

Complete  obliteration  of  the  urethra  is  extremely  rare,  and  it  is  doubtful 
if  it  ever  happens  except  in  the  traumatic  forms  of  stricture  following  extensive 
laceration  or  complete  cross-crushing  of  the  canal.  The  obliteration  in  this, 
case  is  usually  at  least  half  an  inch  wide,  with  fistulae  placed  behind  it. 

SYMPTOMS  OF  STRICTURE 

The  phenomena  produced  by  stricture  vary  with  the  degree  and  the  char- 
acter of  the  narrowing.  They  are  most  conveniently  classified  under  the  fol- 
lowing headings:  1,  subjective  symptoms,  those  recognizable  by  the  patient; 
2,  objective  symptoms,  those  elicited  by  exploration. 

Subjective  Symptoms. — A.  Urethral  History.  Well-planned  questions 
should  elicit  the  fact  that  there  has  been  severe  or  recurrent  urethritis  of  long 
duration;  or  traumatism  to  the  urethra,  perineum,  or  pelvis;  or  a  urethral 
chancre  or  chancroid. 

B.  Alterations  in  Micturition. — 1.  Frequency.  This  arises  at  first  from  the 
change  in  relation  between  the  expulsive  efforts  of  the  bladder  and  the  re- 
sistance offered  by  the  urethra;  afterwards  from  extension  of  inflammation 
backward  by  continuity  until  the  vesical  neck  is  involved;  from  cystitis; 
and  finally  from  atony  of  the  bladder  with  the  presence  of  residual  urine.  In 
these  cases  the  frequency  is  worse  by  day,  as  in  stone,  not  by  night,  as  in 
prostatic  disease. 

2.  Changes  in  the  character  of  the  stream,  which  may  be  double,  flat^ 
gimlet-shaped,  or  spray-like,  and  in  tight  strictures  becomes  much  reduced 
in  size,  are  often  of  slight  significance,  as  the  shape  and  size  of  the  stream 
depend  more  upon  the  shape  and  size  of  the  meatus  than  upon  any  condi- 
tion posterior  to  it. 

3.  Diminution  of  expulsive  power  is  a  late  symptom,  and  is  developed 
only  when  vesical  atony  has  succeeded  the  hypertrophy. 


STRICTURE  OF  THE  URETHRA  255 

4.  Dribbling  after  urination  depends  upon  the  retention  of  some  drops  of 
urine  behind  the  stricture.  These  escape  by  gravity  after  the  act  of  micturi- 
tion is  complete.  It  is  usually  an  early  symptom,  caused  by  irregular  action 
of  the  circular  muscular  fibres  of  the  urethra. 

The  dribbling  from  the  overflow  of  a  distended  bladder  (incontinence 
of  retention)  is  a  very  late  symptom,  and  is  associated  with  a  high  degree 
of  atony  of  the  bladder. 

The  incontinence  of  retention  from  stricture  is  at  first  always  worse  in 
the  daytime,  when  the  patient  is  up  and  about,  while  the  incontinence  of 
retention  due  to  hypertrophy  of  the  prostate  is  worse  at  night,  when  the 
patient  is  lying  down. 

5.  Ardor  urinse  is  very  variable,  but  is  not  apt  to  be  marked  unless  there 
is  a  considerable  degree  of  inflammation  present. 

6.  Retention  of  urine  may  occur  early  and  suddenly  from  an  acute  in- 
crease of  the  congestion  of  the  mucous  membrane  in  the  strictured  region, 
or  it  may  be  a  late  symptom  dependent  upon  the  direct  obstruction  occasioned 
by  the  slowly  contracting  stricture.  In  either  case  it  is  apt  to  be  precipitated 
by  fatigue  or  cold,  or  by  alcoholic  or  sexual  excess. 

7.  Vesical  tenesmus  is  generally  constant  during  the  entire  act  of  micturi- 
tion; that  of  prostatic  hypertrophy  is  most  violent  at  the  beginning  and 
grows  less  as  the  water  begins  to  flow;  that  of  cystitis  is  most  severe  at  the 
end  of  the  act. 

C.  Urethral  Discharge. — Opinions  vary  as  to  the  constancy  of  gleet  as  a 
symptom,  but  it  is  probable  that  a  large  majority  of  strictures  are  accom- 
panied by  it.  Most  of  those  patients  who  exhibit  no  discharge  show  mucous 
and  epithelial  shreds  and  pus-cells  in  the  urine. 

D.  Interference  with  Coition. — The  physiological  congestion  of  erection 
necessarily  makes  the  lumen  of  a  tight  stricture  still  smaller,  thus  causing 
retention  of  semen  behind  the  point  of  narrowing.  This  may  be  extremely 
painful  because  of  the  consequent  distention  of  the  urethra,  often  inflamed  and 
hypersensitive.  On  subsidence  of  erection  the  stricture  may  become  sufficiently 
patulous  to  allow  the  semen  to  drop  slowly  from  the  meatus. 

Ejaculation  is  apt  to  be  premature.  The  erection  is  often  imperfect  or 
subsides  before  the  completion  of  the  act. 

E.  Constitutional  Symptoms. — These  are  late  and  depend  upon  vesical  and 
renal  changes,  with  accompanying  alterations  in  the  urine.  They  are,  there- 
fore, usually  a  combination  of  uraemic  and  septicsemic  symptoms.  There  is 
a  red  glazed  tongue,  with  anorexia,  dyspepsia,  constipation,  etc.  The  dryness 
of  the  tongue  extends  to  the  walls  of  the  pharynx,  making  swallowing  painful ; 
an  irregular  fever  supervenes;  the  general  strength  fails,  the  face  becomes 
pinched  and  yellow,  the  eyes  sunken,  and  after  rapid  emaciation  and  pro- 
found prostration  the  patient  dies  comatose. 

Of  the  subjective  symptoms  frequent  urination,  dribbling,  and  gleet  are 
the  most  characteristic  of  stricture. 

Obiective  Symptoms. — Guyon  divides  the  urethra  into  six  regions: 
1.  The  navicular  region,  extending  from  the  meatus  to  the  corona. 


256  GENITO-URINARY  SURGERY 

2.  The  penile  region,  extending  from  the  corona  to  the  peno-scrotal  junc- 
ture. 

3.  The  scrotal  region,  extending  from  the  anterior  to  the  posterior  scrotal 
wall. 

4.  The  perineo-bulbar  region,  extending  from  the  posterior  scrotal  wall  to 
the  anterior  layer  of  the  triangular  ligament. 

5.  The  membranous  region. 

6.  The  prostatic  region. 

It  must  be  remembered  that  the  superior  urethral  wall  alone  has  anything 
like  a  fixed  curve,  while  the  inferior  wall  is  a  broken  Hne.  The  inferior  wall 
is  extensible,  soft,  and  depressible,  and  is  subject  to  variations  in  form  and 
length;  hence  the  important  point  for  the  surgeon  to  remember  during  urethral 
instrumentation  is  that  he  should  follow  the  curve  of  the  superior  wall,  or 
by  manipulations  modify  the  direction  of  the  urethra.  The  part  most  sus- 
ceptible to  modification  or  change  in  direction  is  that  extending  from  the 
suspensory  ligament  to  the  entrance  into  the  membranous  division;  anatomi- 
cal knowledge  and  the  "touch"  must  be  depended  upon  to  indicate  the  limit 
of  modification  which  the  urethra  will  bear  without  sustaining  a  lesion.  The 
urethra  has  no  lateral  flexions  or  bends,  but  lies  exactly  in  the  median  line. 
Nothing,  however,  is  easier  than  to  produce  such  deviation  in  the  spongy 
urethra,  especially  in  the  bulbar  portion. 

The  elasticity  and  extensibility  of  the  urethra  reside  for  the  most  part  in 
the  spongy  portion,  as  is  clearly  demonstrated  by  erection,  and  this  elasticity 
belongs  in  the  greatest  degree  to  the  inferior  wall,  which  permits  of  easy  dis- 
tention or  elongation,  while  the  superior  wall  yields  with  much  less  readi- 
ness. This  difference  increases  with  age  and  is  especially  marked  in  the  senile 
urethra.  It  is  therefore  evident  that  since  the  extensibility  of  the  inferior 
wall  is  brought  into  play  by  even  a  moderate  force,  the  surgeon  cannot  count 
on  its  resistance.  It  glides  before  an  instrument  and  cannot  serve  to  guide  it. 
It  yields  readily  to  a  mechanical  pressure  testing  its  extensibility;  it  cannot 
be  incised  with  any  accuracy  or  precision;  it  ruptures  when  surprised  by  dis- 
tention. It  does  not  yield  equally  in  all  its  parts,  the  perineo-bulbar  portion 
of  the  canal  being  the  most  distensible  part  of  the  urethra. 

The  superior  wall  is  more  regular  and  constant  in  form  and  direction,  pre- 
sents the  smoother  and  firmer  surface,  is  less  modified  by  mechanical  pressure, 
offers  the  greater  resistance  to  rupture  and  penetration,  is  less  intimately 
connected  with  important  structures,  and  is  the  less  vascular  of  the  two 
walls. 

There  are  three  relatively  constricted  points  in  the  urethra,  the  internal 
and  the  external  meatus,  point  of  passage  through  the  superficial  layer  of  the 
triangular  ligament,  and  three  dilatations,  the  fossa  navicularis,  the  bulbar 
cul-de-sac,  and  the  prostatic  expansion,  all  of  which  present  numerous  indi- 
vidual varieties.  These  dilatations  are  at  the  expense  of  the  inferior  wall  of 
the  canal  (Fig.  130). 

Diagnoses. — The  best  instruments  for  the  diagnosis  of  stricture  of  the 
penile  urethra  are  the  so-called  bougies  a  boule  or  the  Otis  urethrometer. 

The  size  of  the  instrument    (Fig.    131)    selected   for  examination   should 


STRICTURE  OF  THE  URETHRA 


257 


be  determined  approximately  by  noting  the  circumference  of  the  flaccid  penis 
at  the  middle  of  the  spongy  portion.     The  following  is  an  average  scale: 

Circumference   of   penis,   3   inches;  calibre  of   urethra,  26-28   millimetres. 

i%     "  "  "  28-30 

3y2     "  "  "  30-32 

33/4     "  "  "  32-34 

4        "  "  "  34-36 

The  meatus  should  be  cut  if  it  is  too  small  to  perniit  the  introduction  of 
a  bulbous  bougie  of  the  required  size. 

The  penis,  with  the  dorsum  facing  the  abdominal  wall,  is  held  just  behind 
the  corona  between  the  thumb  and  finger  of  the  left  hand,  the  foreskin  having 

/ 

i) 


Fig.  130. — Cast  of  the  urethra,  -a,  navicular  fossa;  b,  membranous 
urethra;  c,  expansion  of  the  bulb.     (Letzel.) 

been  retracted.  The  bougie,  well  oiled,  is  then  passed  gently  to  the  triangular 
ligament.  If  it  is  arrested,  the  point  of  the  shaft  corresponding  to  the  meatus 
is  m.arked  with  the  finger  and  the  instrument  is  withdrawn.  The  distance 
from  the  meatus  to  the  bulb  of  the  bougie  is  then  measured,  and  the  region 


Fig.  131. — Gauge  for  urethral  instruments. 

of  the  contraction  is  carefully  noted.  If  that  instrument  or  a  smaller  size 
passes,  it  is  withdrawn  after  a  moment's  delay,  and  if  during  its  outward 
passage  any  contraction  is  found,  it  is  probably  due  to  stricture,  although  spasm 
may  occasionally  give  rise  to  error  in  diagnosis. 

The  bougie  is  not  passed  into  the  posterior  urethra,  as  the  normal  re- 
sistance of  the  posterior  layer  of  the  triangular  ligament  always  noted  on  its  with- 
drawal from  this  position  renders  its  employment  misleading.  A  sound  should 
be  used  in  the  posterior  part  of  the  canal. 

Solid  steel  sounds,  if  introduced  gently,  nearly  always  pass  without  diffi- 
culty the  narrowing  due  to  spasm.    Pain  is  usually  greater  in  spasm,  but  this 
is  not  sufficiently  constant  to  be  of  diagnostic  value. 
17 


258  GEXITO-URINARY  SURGERY 

When  a  stricture  has  been  detected  with  a  full-sized  bougie  and  the  loca- 
tion of  its  anterior  face  with  reference  to  the  meatus  noted,  bougies  of  pro- 
gressively smaller  cahbre  are  used  till  one  is  found  which  will  slip  through 
the  stricture.  This  instrument  is  then  passed  on  in  till  it  meets  an  obstruc- 
tion or  reaches  the  compressor  muscle,  after  which  it  is  slowly  withdrawn, 
noting  the  position  of  any  points  by  which  the  shoulder  of  the  instrument 
is  caught.  If  the  Otis  urethrometer  is  used  in  the  exploration,  withdrawal 
is  not  necessary  till  all  the  data  have  been  obtained,  as  its  size  can  be 
adjusted  as  desired,  and  a  scale  on  the  handle  indicates  the  depth  to  which 
the  dilating  portion  has  been  inserted.  By  noting  the  size  of  the  instrument 
which  will  pass  through  a  stricture,  and  the  distances  of  its  anterior  and 
posterior  faces  from  the  meatus,  an  excellent  idea  can  be  obtained  of  the 
size,  location,  and  extent  of  the  strictured  areas. 

Sometimes,  when  no  bougie  a  boule  will  pass,  a  steel  sound  several  sizes 
larger  will  do  so  with  ease.  The  information  it  conveys  is  not  so  accurate 
as  that  obtained  by  exploration  with  the  acorn  bougie,  but  is  sufficiently  so 
when  the  stricture  is  of  small  calibre. 

In  making  a  diagnosis  between  deep  stricture  and  hypertrophy  of  the 
prostate  the  history  and  age  of  the  patient  are  important  factors.  In  prostatic 
hypertrophy  the  patient  is  apt  to  be  over  fifty  years  of  age  and  gives  a 
history  of  partial  retention  with  nocturnal  incontinence  of  urine;  the  urethra 
is  lengthened,  so  that  the  shaft  of  a  catheter  must  be  entered  to  an  unusual 
depth  and  the  handle  of  a  metal  instrument  must  be  more  than  ordinarily 
depressed  before  the  beak  reaches  the  bladder;  the  obstruction  will  be  found 
at  a  distance  of  more  than  six  and  a  half  inches  from  the  meatus,  and  a 
finger  in  the  rectum  will  easily  make  out  the  enlarged  prostate,  or  cystoscopic 
examination  will  disclose  an  hypertrophied  median  lobe. 

The  presence,  location,  and  calibre  of  a  stricture  having  been  determined, 
its  dilatability  is  ascertained  by  the  use  of  the  conical  steel  sound;  but  it  is 
usually  advisable  to  make  this  investigation  at  a  subsequent  visit. 

RESULTS  OF  STRICTURE 

Unrelieved  obstruction  of  the  urethral  canal  continued  for  a  prolonged 
period  produces,  in  addition  to  the  local  conditions  already  described,  a  series 
of  changes  in  the  urinary  tract  posterior  to  the  lesion.  Under  long-continued 
and  increasing  pressure  the  urethra  gradually  enlarges,  and  the  mucous  mem- 
brane becomes  thinned  and  pouched,  projecting  in  places  between  the  bands 
of  muscular  fibres,  forming  diverticula  analogous  to  those  seen  in  the  bladder. 
Sometimes,  instead  of  permitting  the  gradual  escape  of  urine  through  minute 
openings,  with  the  formation  of  small  abscesses  and  fistulae,  the  urethra  gives 
way  more  largely  at  a  point  behind  the  stricture,  and  extravasation  of  urine 
follows. 

Extravasation  of  Urine. — This  serious  complication  of  stricture  is  usually 
preceded  by  the  following  symptoms. 

Symptoms. — After  long  continuance  of  the  ordinary  phenomena  due  to 
stricture,  a  tumor  develops  somewhat  suddenly  along  the  course  of  the  urethra, 
accompanied  by  dysuria  and  frequent  micturition  or  by  complete  retention. 


STRICTURE  OF  THE  URETHRA  259 

If  the  extravasation  is  gradual,  this  tumor  will  fluctuate,  open  externally 
as  an  abscess,  and  form  a  urethral  fistula. 

•  If  the  extravasation  is  sudden — i.e.,  if  the  wall  of  limiting  inflammatory 
tissue  thrown  out  at  first  is  suddenly  broken  through  by  the  efforts  at  micturi- 
tion— while  straining  to  evacuate  the  bladder  a  sense  of  something  having 
given  way  is  experienced,  together  with  distinct  relief  of  bladder  tension, 
although  no  urine  escapes  externally,  and  a  smarting  or  burning  pain  is  felt 
about  the  seat  of  rupture. 

The  local  symptoms  are  those  produced  by  the  retention  of  an  irritant 
and  often  a  poisonous  fluid  within  the  tissues.  The  parts  swell  and  become 
cedematous,  the  color  of  the  skin  changes  to  a  dusky  red,  purple,  or  dirty 
brown,  emphysema  occurs  from  the  gases  of  decomposition,  and  spots  of  gan- 
grene appear.  When  the  urine  is  septic,  sloughing  may  set  in  by  the  end 
of  the  first  day. 

The  general  symptoms  are  those  of  profound  septicaemia,  marked  by  great 
prostration,  irregular  temperature,  a  dry,  glazed  tongue,  a  running  pulse,  fre- 
quent shallow  respirations,  wandering  delirium,  and  finally,  if  the  condition 
is  unrelieved,  death  in  coma.  These  develop  with  greater  intensity  and  rapidity 
if  the  bladder  has  been  infected  with  putrefactive  microbes  and  the  urine  is 
therefore  fetid  and  purulent  before  extravasation  takes  place. 

The  localizing  symptoms — those  which  indicate  the  point  at  which  the 
urethra  has  given  way — are  based  upon  the  course  taken  by  the  urine. 

A.  In  case  the  pendulous  urethra  gives  way,  the  result  may  be  as  follows: 

1.  When  the  urine  is  not  septic  and  ammoniacal,  and  the  extravasation  is 
not  very  rapid,  it  may  remain  strictly  limited,  forming  a  blind  internal  fistula. 

2.  The  urine  may  extravasate  into  the  substance  of  the  corpus  spongiosum, 
passing  forward  in  the  course  of  the  urethra,  and  finally  involving  the  glans 
penis  in  the  sloughing  process.  Brodie  states  that  the  appearance  of  a  black 
spot  on  the  glans  penis  after  extravasation  is  a  fatal  sign,  and  Harrison  concurs 
in  this  opinion. 

3.  The  corpus  spongiosum  may  be  protected  by  inflammatory  exudate,  ul- 
ceration extending  to,  but  not  through,  its  strong  fibrous  envelope  (Buck's 
fascia) .  In  this  case  the  urine  may  burrow  forward,  forming  a  long,  indurated, 
fistulous  tract,  opening  externally  behind  the  glans,  or  on  the  dorsal  surface 
near  the  root  of  the  penis. 

4.  Ulceration  may  involve  the  common  fascia  of  the  penis  at  or  near  the 
point  of  rupture.  In  this  case  the  loose  cellular  subcutaneous  tissue  Of  the 
penis  becomes  enormously  (Edematous,  the  swelling  extending  backward  to  the 
scrotum.  This  is  the  common  course  when  rapid  extravasation  takes  place 
from  the  pendulous  urethra. 

B.  When  extravasation  occurs  from  any  portion  of  the  urethra  included 
between  the  attachment  of  the  scrotum  and  the  anterior  layer  of  the  triangular 
ligament,  usually  the  bulbar  portion,  the  course  of  the  extravasated  urine  is 
governed  by  the  attachments  of  the  deep  layer  of  the  superficial  fascia — 
Colles's  fascia.  The  urine  will  first  occupy  the  space  enclosed  by  this  fascia 
in  front  and  below  and  by  the  anterior  layer  of  the  triangular  ligament  behind, 
and,  as  it  cannot  reach  the  ischiorectal  space  on  account  of  the  attachment 


*260  GENITO-URINARY  SURGERY 

of  the  fascia  to  the  base  of  the  ligament,  and  cannot  reach  the  thighs  on 
account  of  the  insertion  of  the  fascia  into  the  ischiopubic  line,  it  is  directed 
into  the  scrotal  tissues,  and  thence  up  between  the  pubic  spine  and  the  sym- 
physis until  it  reaches  the  abdominal  wall. 

C.  In  case  the  membranous  urethra  gives  way,  the  extravasated  urine  is 
confined  to  the  region  included  between  the  layers  of  the  triangular  ligament, 
and  gains  access  to  other  parts  only  after  suppuration  and  sloughing  have 
made  for  it  an  outlet.  The  symptoms  following  will  then  depend  upon  the 
portion  of  the  aponeurotic  wall  which  first  gives  way.  If  the  anterior  layer 
of  the  triangular  ligament  yields,  the  extravasation  will  take  the  course  de- 
scribed as  characteristic  of  extravasation  from  the  bulbous  urethra;  if  the 
posterior  layer  yields,  the  course  of  the  urine  will  correspond  with  that  taken 
when  the  prostatic  urethra  is  ruptured. 

D.  If  the  opening  is  situated  behind  the  posterior  layer  of  the  triangular 
ligament — in  the  prostatic  urethra — the  urine  may  either  follow  the  course 
of  the  rectum  and  make  its  appearance  in  the  anal  perineum,  or,  as  it  is 
separated  from  the  pelvis  only  by  the  thin  pelvic  fascia,  it  may  make  its 
way  through  the  latter  near  the  puboprostatic  ligament,  where  the  fascia  is 
especially  weak,  and  may  spread  rapidly  throug":.  the  subperitoneal  connec- 
tive tissue,  sometimes  forming  abscesses  in  the  hypogastric  region. 

The  usual  source  of  extravasation  is  from  the  bulbous  and  the  membranous 
urethra,  the  urine  infiltrating  the  perineum  and  scrotum  and  mounting  upward 
to  the  belly-walls.  When  extravasation  occurs  from  the  membranous  urethra 
the  anterior  layer  of  the  triangular  ligament  nearly  always  gives  way. 

Prognosis. — The  prognosis  of  extravasation  of  urine,  except  in  those  few 
cases  where  inflammatory  reaction  protects  the  surrounding  tissues  and  where 
local  abscesses  and  fistulae  are  formed,  is  always  grave.  When  the  penile 
urethra  is  involved  the  skin  usually  ulcerates,  thus  allowing  escape  of  urine 
before  the  extravasation  has  become  widespread.  Extravasation  into  the  sub- 
stance of  the  corpora  cavernosa  is  fortunately  rare. 

In  extravasation  from  the  bulbous  or  membranous  urethra  there  is  little 
prospect  of  spontaneous  relief  being  afforded  by  ulceration;  hence  prompt 
interference  is  necessary  to  prevent  widespread  sloughing  and  death  from 
septic  poisoning. 

Extravasation  from  the  prostatic  urethra,  and  extravasation  from  the  mem- 
branous urethra,  with  backward  extension  through  the  posterior  layer  of  the 
triangular  ligament,  are  the  most  dangerous  forms  of  this  complication  of 
stricture,  since  the  symptoms  are  not  so  characteristic  that  immediate  diag- 
nosis can  be  made,  and  since  it  is  difficult  to  drain  the  infected  tissues  thor- 
oughly when  the  infiltration  is  fairly  started. 

Treatment. — The  treatment  of  extravasation  of  urine  is  sufficiently  simple 
in  theory.  The  two  indications  are  prevention  of  further  extravasation  and 
thorough  drainage. 

Further  extravasation  is  prevented  by  external  perineal  urethrotomy  or 
perineal  section.  Usually  an  instrument  can  be  passed,  the  breach  in  the 
urethral  wall  being  upon  the  floor  of  this  channel  and  not  very  large. 


STRICTURE  OF  THE  URETHRA  261 

At  the  same  time  that  the  urethra  is  opened  behind  the  stricture  the  latter 
should  be  thoroughly  divided.  The  entire  infiltrated  area  is  drained  by  long 
multiple  incisions;  it  is  scarcely  possible  to  overdo  this  part  of  the  operation. 
Two  cuts  are  required  for  the  scrotum,  two  or  three  for  the  penis,  and,  if  the 
case  has  lasted  more  than  twenty-four  hours,  three  or  four  for  the  abdominal 
walls.  As  much  of  the  extravasated  urine  as  possible  should  be  squeezed  out 
through  these  cuts  by  vigorous  mechanical  pressure,  and  the  tissues  should  be 
washed  with  bichloride  1  to  4000.  The  cuts  should  be  loosely  packed  with 
iodoform  gauze  and  covered  with  hot  antiseptic  fomentations,  changed  every 
two  hours  (twenty  layers  of  gauze  wrung  out  in  bichloride  1  to  4000  and 
covered  with  oiled  silk). 

When  the  prostatic  urethra  gives  way,  external  perineal  urethrotomy  and 
drainage  may  not  suffice.  If  the  infiltration  has  been  extensive,  the  parietal 
incision  for  suprapubic  cystotomy  will  also  be  required,  the  prevesical  space 
being  irrigated  and  drained.  By  digital  examination  through  the  rectum, 
boggy  or  indurated  areas  can  be  detected  about  the  base  of  the  bladder  and 
must  be  opened  and  drained  through  the  perineum. 

Bladder. — The  bladder  becomes  affected  as  the  stricture  narrows.  Occa- 
sionally, when  the  obstruction  occurs  suddenly,  the  walls  are  at  once  thinned 
and  atrophied  by  overdistention.  As  a  rule,  however,  a  compensatory  hyper- 
trophy takes  place  first,  the  muscles  become  thick  and  rigid,  the  capacity  of 
the  viscus  diminishes,  and  the  muscular  fibres  stand  out  in  bars  or  ridges, 
having  between  them  lozenge-shaped  spaces  where  the  walls  are  greatly  thinned. 
During  the  frequent  and  violent  contractions  of  the  viscus  the  mucous 
membrane  is  driven  outward  between  these  muscular  partitions  and  the 
bladder  finally  becomes  pouched  at  a  number  of  places  (see  Plate  V,  c. 
Chapter  V). 

Usually  there  is  also  a  severe  cystitis  developed  by  infection  through  the 
urethra,  adding  greatly  to  the  severity  of  the  symptoms.  Exceptionally  the 
sacculi  rupture,  causing  collapse  and  death. 

Ureters. — The  ureters  become  dilated  partly  from  the  actual  backward 
pressure  of  the  column  of  urine  incident  to  distention  of  the  bladder,  and 
partly  from  the  frequent  compression  of  their  vesical  ends  during  the  oft- 
repeated  acts  of  urination.  Their  oblique  course  through  the  walls  of  the 
bladder  renders  this  compression  very  effective,  and  hydronephrosis  is  developed, 
causing  mechanical  obstruction  to  the  secretion  of  urine. 

Kidneys. — Sooner  or  later  microbic  infection  takes  place  and  the  renal 
alterations  due  to  suppurative  inflammation  follow.  A  pyelonephritis  first 
develops,  and  then  foci  of  suppuration  are  formed  at  different  points  through 
the  cortex  and  beneath  the  capsule,  until  finally  the  kidney  is  converted  into 
a  large  abscess-cavity,  or  into  a  series  of  pus-containing  sacs,  held  together 
by  the  capsule  and  inflammatory  lymph,  and  showing  no  trace  of  the  secreting 
structure.    This  condition  is  called  surgical  kidney. 

Among  the  possible  results  of  stricture  may  be  mentioned  vesical  calculus, 
impotence,  sterility,  rectovesical  fistula,  and  very  rarely  spinal  sclerosis  or  some 
of  the  forms  of  cerebral  disease. 


262  GENITO-URINARY  SURGERY 

PROGNOSIS  OF  STRICTURE 

The  prognosis  as  to  life  depends,  of  course,  on  the  stage  which  has  been 
reached  and  upon  the  estimate  which  may  be  formed  of  the  secondary  organic 
changes  that  have  already  taken  place.  ReHef  of  the  obstruction,  dramage 
and  antisepsis  of  the  bladder,  milk  diet,  renal  antisepsis,  etc.,  often  work 
astonishing  changes  in  apparently  desperate  cases. 

Fenwick  has  forcibly  called  attention  to  the  fact  that  in  the  practical 
treatment  of  stricture  we  too  often  concern  ourselves  merely  with  the  mechani- 
cal removal  of  the  obstruction,  and  do  not  pause  to  ascertain  to  what  extent 
the  secreting  structure  of  the  kidney  has  been  weakened  or  rendered  susceptible 
to  the  invasion  of  inflammation  from  continuous  surfaces. 

Fenwick  emphasizes  the  fact  that  in  the  obstruction  offered  to  the  over- 
flow of  urine  by  unrelieved  stricture  three  muscular  systems — the  vesical, 
the  ureteric,  and  the  cardiac — become  successively  affected  with  hypertrophy. 

TECHNIQUE  OF  URETHRAL  INSTRUMENTATION 

Two  things  are  of  the  utmost  importance  in  all  urethral  manipulations, 
gentleness  and  cleanliness;  of  the  two  gentleness  is  probably  the  more  important. 
Avoidance  of  traumatism  not  only  saves  the  patient  pain,  but  safeguards  him 
by  not  opening  avenues  for  infection. 

There  are  three  ways  in  which  a  patient  may  become  infected  during  urethral 
manipulations — from  bacteria  on  the  instruments  introduced  into  the  urethra, 
from  bacteria  already  present  on  his  genitalia,  and  from  bacteria  on  the  hands 
of  the  surgeon. 

The  first  source  of  danger  is  easily  eliminated  by  the  application  of  adequate 
methods  of  sterilization  (see  Chapter  III). 

The  second  is  a  much  more  difficult  problem,  as  it  is  utterly  impossible  to 
completely  free  the  urethra  and  the  surrounding  skin  of  all  germs.  Yet  prac- 
tically the  following  procedures  yield  satisfactory  results.  So  far  as  the  integu- 
ment is  concerned,  for  such  procedures  as  catheterization  and  the  passage  of 
sounds  it  is  sufficient  to  wipe  off  the  glans  with  cotton  moistened  with  alcohol, 
soap-suds,  or  bichloride  solution;  for  posterior  urethroscopy,  cystoscopy,  and 
cutting  operations  the  penis,  scrotum,  perineum,  and  the  inner  aspect  of  the 
thighs  should  be  scrubbed  with  soap  and  water  and  bichloride  solution.  For 
the  cleansing  of  the  interior  of  the  urethra  we  have  but  one  reliable  antiseptic, 
silver  nitrate  in  strengths  of  1 :  5000  or  greater,  and  this  solution  is  so  irritating 
to  many  patients  that  its  use  is  not  justifiable  as  a  routine  procedure.  We 
therefore  rely  largely  on  mechanical  cleansing  with  bland  solutions.  Of  these 
none  is  better  than  the  patient's  urine  when  this  is  sterile.  When  the  urine 
is  infected  or  the  patient  is  unable  to  void,  the  anterior  urethra  should  be  thor- 
oughly syringed  with  such  solutions  as  normal  saline,  boric  acid,  potassium 
permanganate  (1  to  4000),  protargol  (1  to  2000),  etc. 

For  operative  procedures,  catheterization  of  the  ureters,  etc.,  the  surgeon's 
hands  should  be  scrubbed  and  sterilized  in  the  ordinary  manner,  but  for 
the  simple  office  manipulations  it  is  far  better  and  safer  for  him  to  simply 
wash  his  hands  with  soap   and  water,  and,  considering  them  nonsterile,   to 


STRICTURE  OF  THE  URETHRA 


263 


avoid  touching  any  portion  of  an  instrument  destined  to  be  placed  inside 
the  urethra.  Even  catheterization  with  a  soft-rubber  instrument  can  be  per- 
formed without  touching  the  intra-urethral  portion  of  the  instrument  with 
the  fingers  by  manipulating  it  with  a  pair  of  forceps  (see  Fig.  41). 

As  a  preventive  of  epididymitis  atropine  has  been  used  with  asserted 
good  results  before  the  passage  of  urethral  instruments.  It  is  given  with 
the  idea  of  preventing  spasm  and  reverse  peristalsis  of  the  vasa  following  trau- 
matism to  the  orifices  of  the  ejaculatory  ducts. 

PASSAGE  OF  METAL  INSTRUMENTS 

Urethral  Curve. — The  fixed  curve  of  the  urethra — i.e.,  the  curve  assumed 
by  the  majority  of  adult  urethras  in  a  condition  of  rest — is  measured  from 


^^N^ 


^A F 


Fig.  132. — Tip  of  catheter  just  entering  the  fixed  curve  of  the  urethra.  (Antal.) 
A,  rectum;  B,  bladder;  C,  symphysis  pubis;  D,  seminal  vesicle;  E,  bulb;  F,  tip  of  instru- 
ment entering  the  fixed  curve  of  the  urethra;  G,  prostate. 

just  in  front  of  the  triangular  ligament  to  the  neck  of  the  bladder  (Fig.  132). 
It  is  theoretically  considered  as  that  part  of  a  circle  of  three  and  one-quarter 
inches  diameter  which  is  subtended  by  a  cord  two  and  three-quarters  inches 


264 


GE^'ITO-URIXARY  SURGERY 


long  (Fig.  133).  Practically  this  curve  varies  greatly  from  this  standard. 
Indeed,  it  is  not  a  continuous  curve.  Depressing  the  urethra  by  means  of 
a  finger  placed  on  either  side  of  the  root  of  the  penis  somewhat  straightens 


Fig.  133. — FLxed  urethral  curve. 


the  curve.  It  is  always  lengthened  by  hypertrophy  of  the  prostate  and  may 
be  temporarily  obliterated  by  passing  a  straight  instrument  into  the  bladder 
(Fig.  134). 

Passing  the  Sound. — For  the  passage  of  a  properly  made  steel  sound  or 


3  =S^r-c:^ 


Fig.  134. — Fixed  curve  of  the  urethra  obliterated  by  the  passage  of  a  straight 
instrument.  (Antal.)  A,  rectum;  B,  bladder;  C,  symphysis  pubis;  D,  scrotum;  E,  pros- 
tate; F,  tip  of  catheter  in  bladder. 

silver  catheter,  the  curve  of  which  corresponds  with  that  given  above,  the 
patient  should  be  placed  in  the  recumbent  position,  with  the  head  and  shoulders 
slightly  elevated,  the  knees  a  little  separated,  and  the  muscles  relaxed.  The 
surgeon,  if  right-handed,  stands  at  the  left  side  of  the  patient.     The  sound 


STRICTURE  OF  THE  URETHRA 


265 


or  catheter,  having  been  previously  sterihzed,  warmed,  and  lubricated,  is  taken 
in  the  right  hand,  and,  the  foreskin  having  been  retracted,  the  penis  is 
held  between  the  middle  and  ring  fingers  of  the  left  hand.     The  organ  is 


Fig.  135. — Passing  the  sound.    The  shaft  is  kept  parallel  to  Poupart's  ligament  till  the  tip 

has  reached  the  bulb. 


Fig.   136. — Passing  the  sound.     Handle  carried  to  the  midline. 

gently  put  on  the  stretch,  care  being  taken  to  keep  the  dorsum  towards  the 
abdominal  wall,  so  as  to  avoid  making  twists  in  the  urethra,  the  lips  of  the 
meatus  are  separated  by  the  thumb  and  finger  of  the  left  hand,  and  the  tip 
of  the  instrument  is  passed  into  the  urethra.     At  this  time  the  shaft  of  the 


266 


GENITO-URINARY  SURGERY 


sound  or  catheter  should  be  parallel  to  the  line  of  the  groin  (Fig.  135).  This 
is  important  chiefly  in  persons  with  large,  protuberant  bellies,  in  whom,  if 
this  rule  is  not  followed,  the  tip  of  the  instrument  will  be  made  to  catch  against 
the  anterior  layer  of  the  triangular  ligament,  owing  to  the  elevation  of  the 
handle  necessitated  by  the  prominent  abdomen.  In  any  event,  the  handle  of 
the  instrument  must  be  kept  low  until  the  tip  is  about  to  enter  the  mem- 
branous urethra.  Haying  engaged  the  point  of  the  sound,  the  penis  is  now 
drawn  up  with  the  left  hand,  while  the  instrument  is  gradually  pushed  on- 
ward, until  three  or  four  inches  of  the  shaft  have  disappeared,  when  the  handle 
is  swept  inward  to  the  median  line,  the  shaft  being  kept  parallel  to  the  anterior 
plane  of  the  body  and  nearly  touching  the  abdomen  (Fig.  136).  The  handle 
is  then  raised  from  the  abdominal  wall  and  swept  gently  over  in  the  median 
line,  while  the  left  hand  is  shifted  to  the  perineum  (Fig.  137),  where  it  guides 


Fig.   137. — Passing  the  sound.     Handle  raised  to  bring  tip  into  the  membranous  urethra. 


the  tip  of  the  sound  into  the  membranous  urethra.  After  the  shaft  has 
passed  the  perpendicular,  the  handle  is  taken  in  the  left  hand,  and  the  index 
and  two  fingers  of  the  right  hand  are  placed  one  on  either  side  of  the  root 
of  the  penis,  making  downward  pressure,  while  the  left  hand  depresses  the 
handle  between  the  legs,  carrying  the  point  of  the  instrument  through  the 
membranous  and  the  prostatic  urethra  into  the  bladder  (Fig.  138).  The  en- 
trance into  this  organ  is  recognized  by  the  free  motion  of  the  tip  of  the  sound 
when  the  handle  is  rotated,  and  by  the  fact  that  the  instrument  remains 
exactly  in  the  median  line  and  points  away  from  the  pubes  when  the  hold 
upon  it  is  relaxed  (Fig.  139).  The  whole  manoeuvre  must  be  effected  with 
gentleness;  no  force  is  necessary. 

If  there  is  a  spasm  of  the  circular  muscular  fibres  of  the  urethra  at  any 
point,  or  of  the  compressor  urethrae  at  the  bulbomembranous  juncture,  gentle 
steady  pressure  for  a  minute  or  two  usually  will  be  followed  by  relaxation. 


STRICTURE  OF  THE  URETHRA 


267 


If  the  handle  is  lifted  too  soon  from  its  proximity  to  the  abdominal  wall, 
the  tip  of  the  instrument  catches  in  the  subpubic  ligament  above  the  urethral 
orifice;  or  if  the  handle  is  not  raised  soon  enough,  or  if  the  fingers  on  the 


Fig.  138. — Passing  the  sound.    Handle  carried  toward  patient's  feet,  while  pressure  is  made 
at  the  root  of  the  penis  to  assist  in  obliterating  the  fixed  curve  of  the  urethra. 


Fig.  139. — Position  of  sound  when  tip  has  entered  the  bladder. 

perineum  do  not  give  the  curve  of  the  instrument  the  gentle  upward  pressure 
that  it  needs,  the  tip  buries  itself  in  the  loose  and  movable  floor  of  the  bulbous 
urethra  below  the  orifice  of  the  membranous  portion  of  the  canal  (Fig.  130). 
In  either  case  the  curve  of  the  sound  protrudes  unnaturally  in  the  perineum. 


258  GENITO-URINARY  SURGERY 

The  withdrawal  of  the  instrument  for  an  inch  or  two  and  its  reintroduction, 
raising  or  lowering  the  tip  as  may  be  required,  will  suffice  to  overcome  the 
obstacle. 

If  the  instrument  is  used  with  ordinary  care  and  gentleness  and  has  been 
properly  sterilized,  and  if  it  is  immediately  followed  by  a  total  antiseptic  irri- 
gation (protargol  1  to  2000  to  1  to  200),  the  production  of  prostatitis,  epididy- 
mitis, or  urethral  fever  will  follow  with  extreme  rarity.  In  a  majority  of 
cases  these  complications  are  due  to  the  use  of  force  in  the  introduction  of 
the  bougie,  when  the  instrument  practically  becomes  a  divulsor,  or  to  a  slov- 
enly disregard  of  asepsis,  either  the  instruments  not  having  been  sterilized 
or  the  urethra  not  having  received  irrigation  before  manipulation. 

URETHRAL  FEVER 

Urethral  fever  (urinary  fever,  catheter  fever)  follows  trauma  and  is  due 
to  absorption  of  bacteria  or  toxins  through  a  hypersemic  or  abraded  mucous 
surface. 

Since  the  passage  of  an  instrument  into  the  urethra  has  been  shown  to 
produce  a  sudden,  sometimes  very  pronounced,  fall  of  blood-pressure,  it  is 
not  difficult  to  account  for  the  syncope  so  frequently  observed  as  a  result 
of  even  the  most  gentle  introduction  of  a  sound.  As  a  direct  or  remote  result 
of  this  primary  reflex  influence  on  the  circulation  it  is  conceivable  that  the 
secretory  function  of  diseased  kidneys  may  be  abolished,  and  that  death  may 
result  from  anuria.  Such  cases — i.e.,  those  characterized  by  syncope,  collapse, 
or  anuria,  presenting  all  the  symptoms  of  shock  and  exceptionally  terminating 
fatally  in  a  very  few  hours — are  not  properly  classed  under  urethral  fever, 
and  should  receive  the  immediate  stimulating  treatment  appropriate  to  syncope 
or  shock,  and  afterwards  that  called  for  in  acute  suppression. 

The  reflex  element,  aside  from  primary  syncope,  plays  but  a  minor  role 
in  the  development  of  the  phenomena  known  as  urethral  fever.  Albarran  re- 
ports a  case  of  internal  urethrotomy  in  which  the  bacterium  coli  communis 
was  found  in  the  blood  of  the  patient,  who  died  twelve  hours  after  opera- 
tion, this  same  microorganism  being  discovered  in  the  urethral  pus.  From 
this  and  from  many  similar  cases  it  would  seem  clear  that  even  though  the 
classical  symptoms  of  septic  absorption  are  absent — i.e.,  chill,  fever,  and  sweat 
— and  though  the  case  progresses  to  a  fatal  issue  in  a  few  hours,  this  rapid 
and  irregular  course  does  not  necessarily  imply  a  reflex  nonseptic  inhibition 
of  the  renal  function. 

Retention  of  urine,  with  the  consequent  effects  on  the  bladder  walls  and 
the  kidneys  {i.e.,  chronic  cystitis,  pyelitis,  and  nephritis),  acts  as  a  strong 
predisposing  factor  in  the  development  of  urinary  fever.  As  an  exciting 
cause,  contact  of  infected  urine  or  of  purulent  discharges  with  fissure  or 
abrasion  of  the  mucous  membrane  of  the  urethra  is  sufficient.  Urethral  fever 
by  no  means  follows  as  a  rule  in  consequence  of  such  contact.  It  is  well 
known  that  forcible,  clumsy,  unsuccessful  catheterization,  attended  by  profuse 
bleeding  and  rupture  of  the  urethra,  may  be  followed  by  no  constitutional 
symptoms,  while  the  most  skilful  and  gentle  introduction  of  an  instrument 
may  cause  a  malignant  form  of  urinary  fever. 


STRICTURE  OF  THE  URETHRA  269 

Lesions  situated  behind  stricture  and  seats  of  obstruction,  and  particularly 
lesions  of  the  deep  urethra,  are  more  liable  to  be  followed  by  urinary  fever 
than  are  wounds  so  placed  that  the  septic  fluids  are  not  driven  into  them. 
It  has  been  noted  frequently  that  in  cases  where  urinary  fever  occurred 
each  time  a  stricture  was  sounded,  instruments  could  be  passed  with  im- 
punity on  complete  cure  of  the  narrowing.  In  some  cases  no  fever  develops 
till  after  the  urine  has  come  in  contact  with  the  raw  surface;  thus  it  is  not 
uncommon  to  have  a  posturethrotomy  urinary  fever  delayed  till  from  the 
third  to  the  fifth  day,  when  the  permanent  catheter  is  removed  and  the  urine 
flows  under  pressure  over  the  raw  surfaces.  After  perineal  urethrotomy  and 
cystotomy,  urinary  fever  is  extremely  rare. 

The  constitutional  symptoms  incident  to  rapid  extravasation  of  urine  are 
those  characteristic  of  diffuse  cellulitis,  and  are  not  properly  classed  with' 
urinary  fever. 

Symptoms. — The  particular  form  in  which  urinary  fever  may  manifest 
itself  is  quite  independent  of  the  severity  of  the  exciting  lesion,  since  in  at 
least  one  reported  case,  in  which  death  occurred  a  few  hours  after  the  passage 
of  a  catheter,  no  breach  was  found  in  the  continuity  of  the  mucous  membrane. 
The  character  of  the  fever  is  dependent  on  the  virulence  of  the  germs  and  on 
the  tissue  resistance  of  the  individual. 

Acute  urinary  fever  may  take  either  of  the  two  following  forms:  (1)  single 
paroxysm,  (2)  recurrent  paroxysms. 

Acute  Urinary  Fever. — Single  Paroxysm. — This  is  characterized  by  chill, 
fever,  and  sweat.  The  chill  may  come  on  a  few  minutes  after  catheterization; 
usually  it  follows  the  first  act  of  micturition  subsequent  to  urethral  interfer- 
ence. The  chill  is  pronounced,  the  fever  high,  103°  to  105°  F.,  the  sweat 
copious  (Fig.  140). 

At  the  height  of  the  paroxysm  there  may  be  pain  in  the  head  and  back, 
delirium,  unconsciousness,  dyspnoea,  nausea,  and  vomiting.  Usually  the  pulse 
is  full  and  strong,  the  mind  is  clear,  and  the  patient  feels  comparatively 
well. 

Exceptionally  the  chill  is  unduly  severe  and  prolonged,  lasting  possibly  for 
several  hours;  the  patient  becomes  collapsed,  vomits,  purges,  ceases  to  secrete 
urine,  and  dies  in  a  few  hours,  or  in  one  or  two  days,  of  shock,  of  uraemia,  or 
of  virulent  septic  poisoning. 

The  form  with  recurrent  paroxysms  is  characterized  by  irregular  and  ap- 
parently causeless  elevations  in  temperature,  preceded  by  rigors  or  chills, 
which  are  not  so  well  marked  as  in  the  first  attack,  and  followed  by  sweats. 
The  temperature  in  the  interim  does  not  reach  normal,  the  heart  action  con- 
tinues unduly  rapid.  These  paroxysms  may  occur  several  times  a  day,  or 
the  intervals  may  be  of  one  to  several  days'  duration.  Oppression  in  breathing 
and  congestion  of  the  lungs  are  often  noticed.  In  favorable  cases  these 
attacks  cease  in  a  few  days  or  a  week  and  the  patient  shortly  regains  strength, 
though  not  so  rapidly  as  after  the  single  paroxysm.  When  there  are  foci 
of  suppuration,  as  in  cases  of  pyelonephritis,  prostatic  abscess,  or  limited 
urinary  extravasation,  septicaemia  or  pyaemia  may  develop,  with  characteristic 


270 


GENITO-URINARY  SURGERY 


symptoms,  and,  if  the  infecting  focus  is  not  found  and  drained,  usually  with 
a  fatal  termination. 

Chronic  Urinary  Fever. — This  may  directly  follow  either  of  the  preced- 
ing forms,  or  may  develop  insidiously,  at  times  without  elevation  of  tempera- 
ture. Long-standing  retention,  and  the  consequent  changes  in  the  bladder 
and  kidneys,  are  the  common  predisposing  factors.  The  exciting  factor  is 
infection  incident  to  catheterization,  and  the  foci  of  infection  are  usually  in 
the  kidneys. 


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Fig.  140. — Chart  of  patient  with  acute  single  paroxysmal  urethral  fever.  Infection 
incident  to  segregation.  A  moderate  fever  six  hours  after  instrumentation  was  complicated  by 
a  severe  chill,  lasting  one-half  hour,  accompanied  by  fever  of  105 '4'  degrees.  The  pulse,  after 
the  chill,  was  for  a  time  imperceptible  and  remained  weak  and  rapid  for  twelve  hours. 

Symptoms. — The  symptoms  of  this  form  of  urinary  fever  are  septic  or 
ursemic.  Hectic — i.e.,  irregular  paroxysms  of  chills,  fever,  and  sweat,  with 
progressive  loss  of  strength — may  be  combined  with  dry  brown  tongue,  vom- 
iting, diarrhcea,  headache,  and  stupor.    This  condition  may  last  for  weeks. 

Prognosis. — Urethral  fever,  when  it  appears  as  a  single  paroxysm,  none 
of  the  stages  of  which  are  markedly  severe  or  prolonged,  is  not  especially 
serious.  A  heavy,  prolonged  chill,  especially  if  it  is  associated  with  a  rapid 
pulse-rate  out  of  proportion  to  the  temperature,  and  with  suppression  of 
urine,  always  suggests  a  malignant  and  at  times  a  rapidly  fatal  form  of 
infection. 

In  recurrent  paroxysms,  if  the  kidneys  are  healthy  and  the  patient  is  young, 
the  prognosis  is  fairly  good. 


STRICTURE  OF  THE  URETHRA  271 

In  chronic  urinary  fever  the  prognosis  must  be  guarded.  Old  prostatics 
who  have  suffered  long  before  being  relieved  usually  die  when  this  form  of 
urinary  fever  develops;  indeed,  it  is  commonly  a  sign  of  septic  infection  of 
the  kidneys.  In  younger  men  with  retention  from  stricture  the  prognosis  is 
somewhat  more  favorable. 

For  the  prevention  of  the  development  of  urethral  fever  rigid  asepsis  and 
the  greatest  gentleness  should  characterize  all  operations  on  the  urethra  and 
bladder,  especially  in  the  presence  of  retention  of  urine.  When  the  opera- 
tion is  planned  some  time  in  advance,  forty  to  sixty  grains  of  hexamethyle- 
namine  should  be  given  during  the  preceding  twenty-four  hours,  and  if  the 
urine  be  not  strongly  acid  ninety  grains  of  the  acid  phosphate  of  sodium 
should  also  be  administered.  The  urethra  should  be  flushed  out  with  a 
sterile  solution  (silver  nitrate,  1  to  5000;  potassium  permanganate,  1  to  4000; 
boric  acid,  2  to  4  per  cent.;  normal  saline  solution)  before  any  instrument 
is  introduced,  and  at  the  close  of  the  operation  or  examination,  both  it  and 
the  bladder  should  receive  a  thorough,  gentle  lavage. 

Treatment. — Before  operating  on  the  urethra  a  preliminary  bacteriologi- 
cal examination  of  the  urine  is  advisable.  If  virulent  colonies  of  the  colon 
group  are  found,  it  is  well  to  postpone  operation  till  these  have  disappeared 
as  a  result  of  internal  vaccine  and  local  cleansing  treatment,  or  if  surgical 
interference  is  urgently  demanded  this  should  be  followed  by  perineal  drainage. 

Acute  urinary  fever,  characterized  by  a  single  paroxysm  or  by  recurring 
paroxysms,  provided  the  urine  is  abundant  and  normal  and  the  circulation  is 
not  materially  disturbed,  requires  only  rest  in  bed,  the  administration  of 
urinary  antiseptics,  a  bland  liquid  diet,  preferably  milk,  and  a  mild  saline, 
Hunyadi  or  magnesium  sulphate,  in  sufficient  doses  to  cause  three  loose  passages 
a  day. 

When  the  constitutional  symptoms  are  well  marked,  the  pulse  becoming 
progressively  more  rapid  and  feeble,  stimulants  and  tonics  are  indicated,  much 
the  same  treatment  being  pursued  as  for  septicaemia.  Should  the  urine  become 
loaded  with  albumen  or  contain  blood,  or  should  the  kidneys  cease  to  secrete, 
dry  cups  over  the  loins,  a  half-dozen  to  each  side,  full  doses  of  tincture  of 
digitalis,  a  teaspoonful  thrice  daily  (Otis),  and  on  the  supervention  of  uraemic 
symptoms  the  hot  vapor  bath,  repeated  according  to  the  indications,  are  the 
measures  which  promise  best  results. 

When  in  spite  of  careful  local  and  general  treatment  symptoms  of  septic 
absorption  are  steadily  progressive,  perineal  drainage  should  be  established, 
supplemented  by  copious  urethral  and  vesical  irrigations.  This  operation  is 
indicated  only  when  the  urethra,  prostate,  or  bladder  exhibits  possible  foci 
of  infection,  or  when  a  pyelonephritis,  the  usual  cause  of  the  toxic  symptoms, 
is  exaggerated  by  an  inadequately  drained  bladder.  In  the  absence  of  such 
conditions  it  is  not  only  futile  but  is  often  promptly  fatal. 

TREATMENT  OF  ORGANIC  STRICTURE 

The  treatment  of  stricture  in  the  male  may  be  summarized  as  follows: 
1.  Narrowings  at  or  near  the  meatus,   if   treated  at   all,   are  always  cut 
(meatotomy). 


272  GENITO-URINARY  SURGERY 

2.  Strictures  of  large  calibre  (greater  than  15  F.)  are  treated  by  gradual 
dilatation.  Cutting  is  almost  never  required  when  such  a  stricture  is  in  the 
deep  urethra;  it  is  sometimes  necessary  when  the  stricture  is  anterior  to  the 
bulbomembranous  juncture. 

3.  Strictures  of  small  calibre  are  treated  by  gradual  dilatation  if  possible; 
when  in  the  deep  urethra  they  occasionally  require  external  urethrotomy; 
when  anterior  to  the  bulbomembranous  juncture  they  usually  require  internal 
urethrotomy. 

4.  Impermeable  strictures  are  treated  by  perineal  section;  at  times  excision 
and  mucous  membrane  grafting  are  indicated. 

5.  Soft,  recent,  uncomplicated  strictures  are  always  dilated. 

6.  Fibrous  (traumatic),  nodular,  and  irritable  strictures  and  those  compli- 
cated by  fistula  are  always  cut. 

GRADUAL  DILATATION 

The  instruments  for  the  gradual  dilatation  of  stricture  consist  of  a  set 
of  whalebone  filiform  bougies;  a  set  of  tunnelled  catheters,  ranging  from  No.  8 
or  10  to  No.  18  French  (Fig.  141);  a  set  of  Van  Buren's  conical  steel  sounds, 
running  from  No.  12  to  No.  36  French;  and  flexible  bougies — acorn,  conical, 
and  bulbous  or  olive-tipped. 

Though  the  conical  steel  sounds  are  commonly  used  in  the  curative  treat- 


FiG.   141. — Tunnelled  catheter.     Enlargement  of  tip  showing  posi- 
tion of  tunnel. 

ment  of  strictures  of  large  calibre,  the  woven  bougies  with  lead  core  bulbous 
tip  and  flexible  neck  behind  this  tip  are  at  times  invaluable.  This  is  particularly 
the  case  when  the  opening  of  the  stricture  is  eccentric,  and  for  small-calibre 
strictures.  The  flexible  instrument  under  such  circumstances  allows  of  easy 
penetration  with  the  least  possible  amount  *of  traumatism,  and  can  often  be 
passed  without  difficulty  when  the  introduction  of  steel  sounds  is  impossible. 

The  method  of  treating  stricture  by  gradual  dilatation  consists  in  the 
passage  of  instruments  of  increasing  gauge  at  intervals  of  from  three  to  five 
days,  till  the  stricture  readily  admits  an  instrument  corresponding  in  size  to 
the  normal  calibre  of  the  urethra. 

Each  sounding  is  followed  by  a  slight  and  transitory  hypersemia  of  the 
region  about  the  stricture,  and  during  this  time,  particularly  in  recent  cases, 
there  is  an  appreciable  softening  and  absorption  of  the  stricture  tissue.  This 
period  lasts  from  three  to  four  days,  and  not  until  it  subsides  is  the  passage 
of  an  instrument  to  be  repeated. 

Ordinarily  an  advance  of  one  or  two  numbers  of  the  French  scale  may 
be  made  each  time,  but  occasionally  the  same  instrument  must  be  introduced 
at  several  sittings  before  it  can  be  exchanged  for  a  larger  one.    This  is  deter- 


STRICTURE  OF  THE  URETHRA  273 

mined  by  the  degree  of  resistance  experienced  during  its  introduction,  the  pain 
which  it  excites  at  the  time  and  afterwards,  and  the  presence  or  absence  of 
bleeding.  Personal  experience  soon  becomes  the  best  guide  as  to  the  degree 
to  which  dilatation  may  be  carried  at  any  one  sitting,  though  the  feelings  of 
the  patient  should  always  be  consulted.  When  the  full  size  has  been  reached 
{vide  table^  p.  257)  the  symptoms  will  usually  disappear,  and  after  this  it 
is  only  necessary  to  carry  on  the  dilatation  at  increasingly  longer  interv^als  to 
maintain  the  calibre  of  the  urethra. 

A  certain  proportion  of  cases  under  this  plan  of  treatment  will  get  entirely 
well,  so  that  years  afterwards  no  trace  of  stricture  can  be  discovered.  Others, 
if  the  intervals  between  the  introduction  of  the  sound  are  too  long,  will  have 
a  slight  recontraction,  evidenced  possibly  by  a  recurrent  gleet,  and  the  treat- 
ment will  have  to  be  repeated. 

The  introduction  of  a  sound  into  any  stricture  which  it  fills  without  caus- 
ing laceration  is  accompanied  by  certain  phenomena.  There  is  felt,  at  the  end 
of  a  minute  or  two,  a  difficulty  in  withdrawing  the  instrument.  Soon  the  spasm 
disappears,  and  movement  of  the  sound  becomes  easy  again.  Some  hours 
later  a  muco-purulent  discharge  is  established  in  the  canal,  and  in  a  few 
days  the  stricture  allows  the  passage  of  a  larger  sound.  The  permanent  en- 
largement obtained  is  principally  due  to  absorption  incident  to  the  congestion 
excited  in  the  stricture  by  the  presence  of  the  foreign  body,  and  not  to  the 
mechanical  dilatation  and  pressure  of  the  sound.  Therefore,  when  it  is  desired 
to  make  this  inflammation  a  little  more  severe,  it  is  well  to  leave  the  sound 
in  situ  for  five  or  ten  minutes.  The  point  may  be  withdrawn  a  little  during 
this  time,  to  avoid  irritation  of  the  bladder.  The  effect  of  sounds  of  gradually 
increasing  size  is  to  stimulate  the  work  of  absorption  and  to  cause  the  con- 
tractile elements  to  atrophy  and  the  urethra  to  resume  approximately  its  normal 
character. 

These  remarks  apply  to  all  strictures  except  those  complicated  with  ab- 
scesses, fistulae,  urinary  extravasation,  etc.,  or  those  in  which  there  is  marked 
resiliency,  or  where  instrumentation  is  followed  by  rigors  and  urethral  fever. 

All  surgeons  are  agreed  that  uncomplicated  strictures  of  large  calibre  should 
be  treated  by  gradual  dilatation  when  they  are  at  or  behind  the  bulbomem- 
branous  juncture.  Moreover,  tliere  is  a  general  belief  that  uncomplicated 
large-caHbre  strictures  of  the  pendulous  urethra  should  be  given  a  fair  trial 
at  this  method  before  urethrotomy  is  advised. 

Strictures  of  Small  Calibre. — In  beginning  the  treatment  of  a  stricture 
of  small  calibre  it  is  best  to  pass  through  it  a  steel  sound,  provided  its  intro- 
duction requires  no  force.  It  is  not  safe  to  use  a  sound  smaller  than  No.  8 
or  No.  10  of  the  French  scale,  as  even  in  the  most  skilful  and  experienced 
hands  there  is  an  unavoidable  danger  of  lacerating  the  inflamed  and  de- 
generated mucous  membrane  around  the  strictured  region.  It  is  in  the  ex- 
ploration of  deep  stricture  of  small  calibre  that  "false  passages"  are  made, 
and  usually  with  small  metallic  instruments,  either  sounds  or  catheters.  The 
mucous  membrane  in  front  of  a  tight  stricture  is  generally  inflamed  and  soft- 
ened, and  thus  offers  but  little  resistance  to  the  point  of  an  instrument. 

When  a  false  passage  is  made,  the  sensation  conveyed  to  the  hand  differs 
18 


274  GEXITO-URIXARY  SURGERY 

markedly  from  that  attending  a  successful  catheterization.  The  point  of  the 
instrument  is  not  in  the  median  Hne,  and  is  held  with  unusual  firmness.  There 
is  bleeding,  and  the  finger  in  the  rectum  detects  the  deflection  of  the  instru- 
ment, and  the  absence  of  the  normal  thickness  of  urethral  and  prostatic 
tissue  beneath  its  curve.  The  immediate  treatment  after  making  a  false  passage 
consists  in  rest  in  bed,  urethral  and  urinary  antisepsis,  continuous  catheteriza- 
tion for  some  days  (if  a  catheter  can  be  inserted),  and  the  avoidance  of  further 
instrumentation  for  some  weeks.  Should  perineal  abscess  or  urinary  infiltra- 
tion follow,  prompt  incision  is  indicated. 

If  a  sound  is  passed  through  a  stricture  of  small  calibre,  it  should  remain 
five  or  ten  minutes  and  then  be  withdrawm.  Thereafter  it  is  best  to  wait  three 
or  four  days  before  passing  another  instrument,  in  the  meantime  administer- 
ing five-grain  doses  of  salol  or  urotropine  four  to  six  times  daily,  with  a  full 
dose  of  quinine  morning  and  evening.  At  the  next  sitting  it  is  well  to  recom- 
mence with  the  same  instrument,  after  which  one,  two,  or  three  larger  sizes 
may  be  used  in  succession,  provided  their  introduction  is  easy  and  not  ac- 
companied by  pain  or  bleeding.  Hemorrhage  and  pain  are  indications  for 
lengthening  the  intervals  between  treatments  and  for  more  slow^ly  increasing 
the  size  of  the  instruments  used. 

Once  fairly  established,  however,  the  treatment  by  dilatation  is  carried 
on  until  the  full  normal  calibre  is  reached;  usually  this  requires  from  three 
to  twelve  weeks. 

If  the  stricture  is  not  resilient  or  irritable,  and  is  not  traumatic  in  its  origin^ 
it  will  then  be  found  that  all  symptoms  have  disappeared,  unless  perhaps  the 
gleet  persists  for  a  time.  This,  too,  will  often  have  subsided;  but,  in  view 
of  the  extensive  and  serious  urethral  lesions  always  associated  with  long-stand- 
ing stricture,  it  is  apparent  that  gleet  ma\'  persist  in  spite  of  full  dilatation, 
even  though  it  is  reinforced  by  most  careful  local  and  general  treatment. 

When  the  stricture  is  a  recent  one,  complete  absorption  of  all  fibrous  tissue 
may  take  place,  but  in  any  event  the  occasional  introduction  of  a  steel  sound 
will  always  keep  the  case  under  control. 

Strictures  of  Small  Calibre  Permeable  Only  to  FLLrFOR:^!  Bougies. — 
In  certain  cases  no  steel  sound  or  ordinary  soft  instrument  can  be  made  to 
pass  the  stricture,  but  a  persevering  trial  with  whalebone  filiform  bougies 
wall  result  in  the  passage  of  one  into  the  bladder.  This  trial  should  be  made 
persistently  and  patiently,  and  in  the  absence  of  retention  of  urine  may  be 
frequently  repeated.  After  anaesthetizing  the  urethra  and  relie\dng  local  con- 
gestion by  an  instillation  of  adrenalin  chloride,  1  to  2000  in  a  four  per  cent, 
eucaine  solution,  the  urethra  is  slightly  overdistended  anterior  to  the  stric- 
ture with  sterile  oil  injected  by  means  of  a  piston  syringe.  A  filiform  is 
passed  down  to  the  stricture,  and  if,  after  patient,  gentle  effort,  it  refuses 
to  enter,  it  is  \sathdrawn,  and  is  given  an  angle  of  forty-five  degrees  by  bending 
it  across  the  thumb-nail  at  about  a  quarter  of  an  inch  from  the  end.  As  the 
orifice  of  a  tight  stricture  is  frequently  not  in  the  middle  of  the  obstructed 
urethra,  but  at  some  point  around  its  circumference,  this  manoeuvre  will  often 
enable  the  surgeon  to  enter  it  when  with  a  perfectly  straight  instrument  he 
cannot  do  so.     If  this  does  not  succeed,  several  filiforms  are  passed  by  the 


STRICTURE  OF  THE  URETHRA 


275 


side  of  the  first  one,  to  impinge  on  the  irregular  surface  of  the  stricture  at  a 
number  of  points;  then  by  attempting  to  pass  first  one  and  then  another  of 
these  (Fig.  142)  the  filiform  bearing  the  right  relation  to  the  orifice  will 
usually  be  found  and  can  be  introduced  into  the  bladder.  If  this  fails  and 
one  filiform  can  merely  be  engaged  in  the  stricture,  it  is  often  best,  in  the 
absence  of  retention,  to  tie  it  in  place  (Fig.  143)  and  allow  it  to  remain 
for  twenty-four  hours.  In  the  great  majority  of  cases  at  the  end  of  this  time 
it  can  be  passed  through  the  stricture.  After  the  first  instrument  is  intro- 
duced, four  courses  are  open  to  the  surgeon. 

A.  Continuous  Dilatation. — 1.  The  filiform  may  remain  in  place,  with  the 
certainty  that  in  one  or  two  days  others  may  be  slipped  alongside  of  it,  and 


i 


Fig.  142. — Method  of  passing  a  filiform  bougie  through  a  small  stricture. 

may  be  used  as  guides  for  the  introduction  first  of  a  tunnelled  catheter  and 
later  of  an  ordinary  soft  or  steel  instrument. 

2.  An  immediate  attempt  may  be  made  to  pass  into  the  bladder  a  tun- 
nelled catheter  (Fig.  144),  and  if  successful  leaving  it  to  act  for  twenty-four 
hours  by  continuous  dilatation;  later,  gradual  dilatation  may  be  employed. 

B.  Urethrotomy. — 3.  A  tunnelled  and  grooved  staff  may  be  passed  over 
the  filiform,  and  external  urethrotomy  may  be  performed. 

4.  The  filiform  may  be  used  as  a  guide  for  a  Maisonneuve  urethrotome,  and 
internal  urethrotomy  may  be  performed. 

If  the  stricture  which  is  being  dealt  with  is  not  of  traumatic  origin,  and  is 
not  especially  resilient  or  irritable,  the  first  method  will  lead  to  the  adoption 


276 


GENITO-URINARY  SURGERY 


of  gradual  dilatation  with  the  greatest  degree  of  comfort  and  absence  of  anxiety 
to  both  the  patient  and  the  surgeon.  Even  if  there  has  been  moderate  reten- 
tion, it  is  certain  that  the  urine  will  pass  with  increasing  freedom  by  the  side 


Fig.   143. — Filiform  whalebone  bougie  tied  in  the  urethra  after  entering  the  stricture. 


Fig.  144. — Method  of  passing  Gouley's  tunneled  catheter. 


STRICTURE  OF  THE  URETHRA  277 

of  the  filiform,  and  that  the  danger  of  the  case  is  over  so  far  as  retention  is 
concerned. 

-  If  retention  has  been  complete  for  many  hours  and  it  is  necessary  to  give 
immediate  relief  to  the  overstretched  bladder-walls,  it  is  best  to  adopt  the 
second  method — that  is,  pass  a  catheter  at  once.  Failing  in  this,  the  third 
method,  or  external  perineal  urethrotomy,  should  be  employed.  In  all  deep 
strictures  when  instrumentation  occasions  rigors  the  external  cutting  operation 
is  indicated. 

Internal  urethrotomy  is  practised  in  cases  of  tight,  bulbomembranous  stric- 
ture complicated  by  retention  only  when  the  patient  refuses  to  have  the  external 
operation  performed.  In  the  best  hands  it  is  attended  with  a  distinctly  larger 
mortality  than  any  of  the  other  methods  mentioned,  and  there  is  no  evidence 
that  it  is  followed  by  any  larger  percentage  of  permanent  cures. 

CONTINUOUS  DILATATION 

As  intimated  above,  continuous  dilatation  is  particularly  applicable  to  those 
cases  in  which  nothing  larger  than  a  filiform  bougie  can  be  passed  through  a 
stricture.  It  is  also  applicable  to  those  strictures  which  do  not  respond  well 
to  gradual  dilatation,  particularly  in  the  presence  of  strong  contra-indications 
to  urethrotomy. 

Instruments  are  retained  in  the  urethra  by  tying  them  in  some  manner 
to  the  exterior  of  the  penis.  Filiform  bougies  can  sometimes  be  retained  by 
passing  a  piece  of  heavy  silk  around  the  penis  just  back  of  the  glans  and  tying 
its  ends  about  the  bougie  (see  Fig.  143).  This  forms  a  light,  comfortable 
dressing,  but  one  which  is  not  so  secure  as  that  usually  employed  for  the 
retention  of  catheters  (see  Figs.  43  and  44),-  consisting  of  straps  of  adhesive 
plaster  applied  to  the  sides  of  the  penis,  having  silk  or  linen  threads  attached 
to  their  ends.  When  a  woven  catheter  is  used  its  surface  should  be  protected 
from  the  pressure  of  the  threads  by  a  wrapping  of  adhesive  plaster. 

A  case  being  treated  by  continuous  dilatation  should  receive  a  urinary 
antiseptic  (as  hexamethylenamine,  40  to  60  grains  a  day).  The  bougie  or 
catheter  should  be  removed  daily  and  the  urethra  irrigated.  A  freshly  sterilized 
instrument  should  then  be  inserted,  preferably  one  a  little  larger  than  the  one 
previously  worn. 

An  inlying  filiform  bougie  should  extend  through  the  stricture;  it  is  not 
essential  or  desirable  that  it  extend  into  the  bladder.  A  catheter  used  in  this 
manner  should  be  so  placed  that  its  eye  lies  just  within  the  bladder,  this 
position  being  recognized  by  the  fact  that,  while  urine  flows  through  it  while 
in  this  position,  if  it  is  drawn  further, out  the  flow  ceases. 

The  treatment  is  most  easily  carried  out  with  the  patient  in  bed,  but  can 
usually  be  utilized  in  ambulant  cases  with  a  little  trouble. 

Bougies  cause  more  annoyance  than  catheters,  as  urine  leaks  beside  them 
to  a  greater  extent.  (No  fear  need  be  entertained  that  the  patient  will  not 
be  able  to  urinate;  the  instrument  tends  to  relax  the  spasm,  and  the  wearer 
can  always  pass  his  water  with  ease.)  For  this  reason  a  dressing  must  be 
arranged  to  absorb  the  overflow;  a  gonorrhoea!  bag  makes  a  convenient  holder 
for  such  a  dressing.    Catheters,  in  ambulant  cases,  must,  of  course,  be  clamped; 


278  GENITO-URINARY  SURGERY 

when  used  in  bed-patients  they  may  be  attached  to  rubber  tubing  leading  to 
a  bottle  at  the  side  of  the  bed. 

URETHROTOMY 

A  stricture  may  be  divided  entirely  from  within  the  urethra,  in  which  case 
the  operation  is  termed  internal  urethrotomy;  it  may  be  divided  by  an 
incision  carried  through  the  overlying  integument  and  fascia — external 
urethrotomy;  or  both  of  these  methods  may  be  employed — combined  in- 
ternal AND  EXTERNAL  URETHROTOMY.  The  division  of  uarrowings  at  or 
near  the  meatus  is  spoken  of  as  meatotomy. 

Meatotomy. — This  operation  may  be  required  in  connection  with  more 
extensive  stricture-division,  or  as  the  sole  operative  procedure.  When  enlarge- 
ment of  the  meatus  is  necessary  it  is  the  only  method  to  be  considered,  as 
attempts  at  dilatation  are  not  only  painful  but  quite  unavailing.  Under  local 
anaesthesia  it  is  performed  as  follows: 

Eucaine  (4  per  cent.)  is  applied  to  the  interior  of  the  meatus  by  means 
of  a  cotton-wrapped  applicator.  This  is  removed  after  a  minute,  and  the  needle 
of  a  hypodermic  syringe  filled  with  eucaine  solution  (1  per  cent.)  is  inserted 
into  the  floor  of  the  urethra  just  within  the  meatus,  and  the  region  of  the 
obstruction  thoroughly  infiltrated.  The  application  of  a  10  per  cent,  solu- 
tion of  cocaine  on  cotton  to  the  interior  of  the  meatus  sometimes  produces 
anaesthesia,  but  is  not  so  reliable  as  the  method  described.  An  incision  is  then 
made  with  a  meatotome  or  blunt  tenotome  in  the  median  line  (on  the  floor) 
of  sufficient  extent  to  allow  a  bougie  a  boule  of  the  desired  size  to  pass  freely. 
After  meatotomy  the  size  should  be  between  28  and  38  F.,  according  to  the 
condition  of  the  remainder  of  the  urethra,  it  not  being  desirable  that  the 
meatus  should  be  larger  than  the  remainder  of  the  canal.  Sounds  should  be 
passed  twice  a  week  to  prevent  the  cut  surfaces  reuniting. 

Internal  Urethrotomy.— The  different  methods  employed  in  the  internal 
division  of  stricture  depend  upon  the  direction  and  location  of  the  incision. 
This  may  be  made  (a)  from  before  backward  or  (b)  from  behind  forward; 
(c)  on  the  roof  or  (d)  on  the  floor  of  the  urethra. 

Indications  for  the  Performance  of  Internal  Urethrotomy. — This  oper- 
ation is  indicated:   1.  In  all  strictures  at  or  near  the  meatus. 

2.  In  fibrous,  resilient,  or  irritable  strictures  of  large  calibre  anterior  to 
the  bulbomembranous  juncture'. 

3.  In  strictures  of  small  calibre  situated  in  advance  of  the  bulbomem- 
branous juncture,  except  when  such  strictures  are  very  recent,  soft,  and  dilat- 
able. 

Or,  still  further  to  simplify  the  indications,  it  may  be  stated  that  all  fibrous, 
resilient,  or  irritable  strictures  anterior  to  the  bulbomembranous  juncture  should 
be  treated  by  internal  urethrotomy. 

Resiliency  and  resistance  to  dilatation  are  the  chief  indications  for  prefer- 
ring the  cutting  operation  in  the  treatment  of  strictures  of  any  portion  of  the 
urethral  tract;  hence,  even  though  the  coarctations  are  of  large  calibre,  if  they 
are  distinctly  resilient  or  fibrous  urethrotomy  is  indicated. 


STRICTURE  OF  THE  URETHRA 


279 


Strictures  of  small  calibre  situated  in  advance  of  the  bulbomembranous 
juncture,  unless  seen  very  early  and  found  to  be  soft  and  dilatable,  furnish 
the  typical  condition  for  internal  urethrotomy.  In  such  cases  the  operation 
is  attended  with  the  greatest  prospect  of  a  permanent  cure.  The  exceptions 
to  this  rule  will  be  given  in  the  section  devoted  to  combined  internal  and  exter- 
nal urethrotomy. 

Technique  of  the  Operation. — The  antiseptic  details  required  in  internal 


_  / 


Fig.  145. — Urethrotomy  with  Maisonneuve's  urethrotome. 

urethrotomy  are  as  follows:  For  two  days  before  operation  hexamethylenam- 
ine  (40  to  60  grains  a  day)  should  be  given  by  the  mouth.  This  is  particu- 
larly indicated  when  cystitis  is  present  and  the  urine  is  infected.  The  urethra 
is  rendered  as  surgically  clean  as  possible  by  irrigation  repeated  night  and 
morning  for  several  days  before  operation,  with  a  final  washing  just  before 
the  introduction  of  the  urethrotome.  The  solutions  used  are  normal  saline, 
a  1  to  4000  lotion  of  potassium  permanganate,  a  1  to  5000  solution  of  silver 
nitrate,  or  a  1  to  1000  protargol  solution.    If  the  stricture  is  permeable,  a  soft 


280  GENITO-URINARY  SURGERY 

catheter  of  small  calibre  is  passed  behind  it  and  the  whole  urethra  is  flushed 
out  with  the  cleansing  lotion,  from  eight  ounces  to  a  pint  being  used  each 
lime;  or  the  washing  is  conducted  with  the  gravity  bag  and  short  urethral 
nozzle. 

Internal  Urethrotomy  from  Before  Backward. — This  operation  is  indicated 
for  strictures  smaller  than  IS  F.;  that  is,  those  which  are  too  small  to  admit 
the  Gerster  instrument.  The  best  instrument  for  its  performance  is  Maison- 
neuve's  urethrotome.  This  is  provided  with  screw-ended  filiform  woven  bougies, 
which  are  first  passed  through  the  stricture  into  the  bladder.  The  filiform  is  . 
then  screwed  to  the  urethrotome,  and  the  latter  is  introduced,  thus  accurately 
guided. 

The  knife  consists  of  a  triangular  blade  on  a  long,  wire-like  handle, 
designed  to  slide  in  a  groove  on  the  upper  side  of  the  instrument.  Three  knives 
are  usually  provided,  cutting  to  16  F.,  18  F.,  and  20  F.,  respectively.  The 
staff  of  the  instrument  has  a  calibre  of  8  F, 

The  operation  is  performed  as  follows:  The  guiding  bougie  is  passed  into 
the  bladder.  The  screw  end  of  this  is  secured  to  the  urethrotome  and  the  tip 
of  the  latter  is  passed  through  the  stricture  into  the  bladder  and  held  in  posi- 
tion by  an  assistant.  The  operator  with  his  left  hand  draws  the  penis  upward 
and  with  his  right  hand  pushes  the  knife  down  till  the  bulbomembranous  juncture 
is  reached,  cutting  on  the  way  any  obstructions  that  may  be  encountered  (Fig. 
145).  When  the  strictures  are  comparatively  soft  the  largest  knife  may  be 
used;  otherwise,  the  smallest  knife  should  be  used  first  and  followed  by  one 
of  larger  size. 

In  internal  urethrotomy  the  Maisonneuve  instrument  is  to  be  considered 
as  a  preliminary  to  further  cutting,  as  the  result  is  satisfactory  only  when  a 
stricture  is  freely  divided,  giving  the  urethra  its  full  calibre. 

Internal  Urethrotomy  from  Behind  Forward. — Among  the  many  instru- 
ments, that  of  Gerster  is  the  most  convenient.  The  extent  to  which  the  cut 
shall  be  made  is  determined  by  the  divergence  of  two  oval  blades  near  the 
tip  of  the  instrument,  the  extent  of  their  divergence  being  regulated  by  a  screw 
on  the  handle  of  the  instrument,  while  a  finger  on  the  side  registered  the  calibre 
attained.  The  knife  is  concealed  in  the  tip  till  ready  for  use,  when  it  is  drawn 
out  and  the  stricture  divided. 

The  operation  is  begun  by  passing  the  instrument  to  the  desired  depth  with 
the  dilating  blades  closed  and  the  knife  sheathed,  and  opening  the  blades  by 
turning  the  milled  wheel  on  the  handle  till  the  desired  size  is  attained  (an 
increase  of  more  than  eight  or  ten  numbers  should  not  be  made  at  one  cut, 
as  the  knife  would  not  then  reach  the  part  of  the  stricture  impinging  on  the 
blades).  While  an  assistant  draws  the  penis  upward  with  the  meatus  exactly 
in  the  sagittal  plane  of  the  body,  the  operator  draws  the  urethrotome  upward 
till  an  obstruction  is  encountered.  The  knife  is  then  drawn  out  of  its  sheath 
and  returned  (Fig.  146),  the  manoeuvre  being  repeated  as  often  as  may  be 
necessary  to  divide  the  stricture.  Strictures  situated  farther  forward  are  di- 
vided in  a  similar  manner  as  they  are  reached.  If  the  desired  size  has  not 
been  attained^  the  urethrotome  is  again  introduced,  the  blades  separated  further, 
and  the  operation  repeated.    When  full  calibre  has  been  attained,  as  indicated  by 


STRICTURE  OF  THE  URETHRA 


281 


the  scale  on  the  instrument,  a  full-sized  sound  is  passed  to  establish  the  fact 
beyond  all  doubt.  The  operation  is  concluded  by  gentle  irrigation  of  the  urethra, 
and  the  insertion  and  retention  of  a  large  soft-rubber  catheter.  A  catheter  is 
kept  in  the  urethra  for  one,  two,  or  three  days,  according  to  the  reaction  excited. 
Each  day  it  is  attached  to  a  fountain  syringe  filled  with  protargol  (1  to  2000) 


Fig.     146. — Urethrotomy  with  Gerster's  urethrotome. 

•  or  some  similar  solution,  and  withdrawn  till  the  solution  flows  out  of  the  meatus 
beside  it,  after  which  it  is  replaced  and  secured  in  its  former  position. 

Urinary  antiseptics  should  be  continued  during  the  first  week  after  ure- 
throtomy.' 

The  essential  feature  of  the  operation  is  that  a  linear  incision  should  be  made 
in  the  roof  of  the  urethra  (except  at  or  near  the  meatus  or  in  the  membranous 
urethra)  through  every  portion  of  stricture  tissue,  the  cut  extending  from  the 
normal  parts  behind  to  the  normal  parts  in  front  of  the  stricture  and  enabling  the 


282 


GENITO-URINARY  SURGERY 


surgeon  to  pass  at  once  an  instrument  two  sizes  larger  than  the  normal  calibre 
of  the  urethra. 

If  the  hemorrhage  is  not  controlled  by  the  catheter  alone,  a  firm  bandage 
should  be  applied  to  the  penis,  or,  if  the  point  of  cutting  is  too  deep  to  be 
reached  in  this  way,  pressure  may  be  applied  to  the  perineum  by  a  compress 
placed  over  the  seat  of  operation  and  the  application  of  a  crossed  of  the  perineum 
bandage  (Fig.  147  and  p.  316).  For  the  temporary  arrest  of  active  hemor- 
rhage perineal  pressure  applied  by  a  padded  cane,  the  ferrule  of  which  is  braced 
against  the  foot-board  of  the  bed,  will  be  found  efficient,  or  digital  compression 
may  be  made  by  an  attendant. 

In  children  internal  urethrotomy  has  the  same  applications  as  in  the  adult, 
but  the  urethrotome  must  be  modified  in  calibre  and  length  to  suit  the  age  of 
the  individual  patient. 

External   Perineal   Urethrotomy. — By   this   operation  the   urethra   is 


Fig.  147. — Crossed  of  the  perineum  bandage. 

opened  by  an  incision  carried  inward  from  the  skin  surface  of  the  perineum.  In 
accordance  with  the  calibre  of  the  stricture,  certain  modifications  will  be  neces- 
sary in  the  performance  of  this  operation. 

Thus,  if  the  stricture  is  permeable,  1,  external  perineal  urethrotomy  with  a 
guide,  or  Syme's  operation,  is  indicated,  a  grooved  staff  being  carried  through 
the  narrowing  and  the  incision  made  on  this. 

If  the  stricture  is  impermeable,  2,  external  perineal  urethrotomy  without 
a  guide,  or  "  perineal  section,"  is  indicated,  a  staff  being  carried  down  to  the 
anterior  face  of  the  stricture  and  the  urethra  being  opened  at  this  point;  sub- 
sequently, aided  by  sight,  the  stricture  is  divided  from  before  backward. 

The  general  indication  for  external  urethrotomy  is  the  existence  in  the  deep 
urethra — i.e.,  at  or  posterior  to  the  bulbomembranous  juncture — of  a  stricture 
not  amenable  to  dilatation.  Under  this  head  will  come  a  great  variety  of  stric- 
tures, which  may  be  classified  as  follows: 


STRICTURE  OF  THE  URETHRA  283 

1.  Stricture  which  is  resilient  or  so  densely  fibrous  that  it  will  not  yield  to 
either  continuous  or  intermittent  dilatation.  Traumatic  stricture  is  typical  of 
this  class  of  cases.  2.  Stricture  behind  which  extravasation  of  urine  has  oc- 
curred. 3.  Stricture  complicated  with  perineal  abscess,  the  latter  being  laid 
open  at  the  same  time  that  the  stricture  is  divided.  4.  Stricture  complicated 
with  fistulae  which  do  not  close  after  full  dilatation.  5.  Stricture  complicated 
■with  a  cystitis  so  intense  that  continuous  drainage  of  the  bladder  is  indicated. 
6.  Stricture  associated  with  enlargement  of  the  prostate  and  refusing  to  yield 
to  dilatation.  7.  Stricture  complicated  with  retention  of  urine  or  with  the 
"  incontinence  of  retention."  The  high  degree  of  atony  of  the  bladder  which 
ordinarily  exists  in  these  cases  renders  perineal  drainage  exceptionally  desirable. 
8.  Stricture  in  which  urethral  fever  follows  instrumentation,  or  in  which  renal 
congestion  or  nephritis  is  known  to  exist. 

External  Perineal  Urethrotomy  with  a  Guide,  or  Syme's  Operation. — 
Syme's  staff  (Fig.  148)  has  a  narrowed  terminal  part  which  is  passed  through 
the  stricture.  Where  this  narrow  portion  joins  the  shaft  there  is  a  shoulder, 
which  rests  against  the  anterior  face  of  the  stricture  when  the  instrument  is  in 
position.  The  patient  is  placed  in  the  Hthotomy  position  after  the  introduction 
of  the  staff. 

The  use  of  the  Syme  staff  is  possible  only  when  the  stricture  will  admit  at 


Fig.  148. — Syme's  grooved  staff. 

least  a  No.  6  F.  instrument;  when  it  is  so  tight  that  nothing  larger  than  a 
filiform  bougie  can  be  passed,  a  grooved  staff  similar  to  Syme's,  but  with  a 
quarter  of  an  inch  of  its  extremity  bridged  over  so  as  to  convert  the  groove  into 
a  canal,  a  "  tunnelled  catheter  staff  "  is  used,  and  is  threaded  over  a  fihform 
bougie. 

In  whatever  way  the  staff  has  been  passed,  the  assistant  who  holds  it  is 
directed  to  make  its  convexity  bulge  in  the  perineum.  The  left  forefinger  of 
the  operator  is  inserted  into  the  rectum,  and  an  incision  is  made  one  inch  in 
front  of  the  anus  and  exactly  in  the  median  line  of  the  perineum.  This  incision 
is  deepened  till  the  knife-point  enters  the  groove  of  the  narrow  part  of  the  staff, 
"usually  behind  the  stricture.  The  latter  is  then  divided  by  cutting  from  behind 
forward  until  the  projecting  shoulder  of  the  staff  is  freed  and  passes  onward 
towards  the  bladder  without  difficulty.  A  director  or  Teale's  probe  gorget 
(Fig.  149)  is  now  introduced  along  the  groove  of  the  staff  into  the  bladder, 
and  the  staff  is  withdrawn.  Finally,  a  rubber  catheter,  No.  24  to  No.  28  F., 
is  passed  from  the  meatus  into  the  bladder,  guided  by  the  director  or  gorget, 
and  aided  in  its  course  by  manipulation  through  the  wound.  The  catheter  is 
retained  for  one,  two,  or  three  days,  according  to  the  reaction  excited.  In 
from  five  to  seven  days  a  full-sized  sound  is  passed  through  the  penile  urethra 
into  the  bladder,  and  this  is  repeated  every  third  day  for  a  month,  after  which 
the  intervals  between  instrumentation  may  be  made  progressively  longer. 


284  GENITO-URINARY  SURGERY 

If  the  filiform  passes,  but  the  tip  of  the  tunnelled  staff  cannot  be  forced 
through  the  stricture,  the  latter  is  held  in  contact  with  the  anterior  surface  of 
the  narrowing  by  an  assistant,  and  is  exposed  by  a  free  incision  in  the  median 
line  of.  the  perineum,  splitting  the  urethra  in  front  of  the  stricture;  a  loop 
of  silk  is  then  passed  through  each  edge  of  the  divided  urethra  close  to  the  face 
of  the  narrowing,  thus  enabling  the  canal  to  be  held  open.  The  staff  is  with- 
drawn a  litte  in  order  to  bring  the  black  filiform  into  view,  and  then  the  stric- 
ture is  divided  from  before  backward,  together  with  half  an  inch  of  the  un- 
contracted  canal  behind  it.  The  last  step  consists  in  passing  the  staff,  guided 
by  the  filiform,  into  the  bladder.  The  subsequent  treatment  is  the  same  as  in 
Syme's  operation. 

The  Prognosis  of  Stricture  after  External  Perineal  Urethrotomy. — 
The  thorough  division  of  stricture  by  external  urethrotomy  occasionally  results 
in  cure  without  further  treatment.  This,  according  to  Guyon,  is' because  the 
elastic  fibres  of  the  urethra  run  circularly ;  when  cut  they  retract,  and  restoration 
of  the  urethral  lumen  is  accomplished  by  means  of  a  wide  scar,  which  usually 
does  not  contract  sufficiently  to  produce  stricture  again. 

It  is  possible  that  recent  strictures  unattended  by  submucous  fibroid  infiltra- 
tion can  be  cured  by  either  gradual  dilatation  or  section.    When  there  is  distinct 


Fig.  149. — Teale's  probe-ended  gorget. 

fibroid  periurethral  infiltration,  with  decided  alteration  of  the  mucous  rhembrane, 
section,  followed  by  a  prolonged  course  of  gradual  dilatation,  will  usually  accom- 
plish a  practical  but  not  a  truly  radical  cure.  In  densely  fibrous  nodular 
stricture  a  radical  cure  can  be  attempted  only  by  means  of  excision,  and  even 
then  will  probably  not  be  attained:  hence,  though  a  stricture  be  cut,  either 
internally  or  externally,  the  intermittent  use  of  the  sound  for  a  long  period 
should  be  advised. 

Combined  Internal  and  External  Urethrotomy. — This  operation  is 
described  by  Reginal  Harrison,  its  chief  advocate,  as  follows:  The  stricture  is 
divided  by  means  of  a  urethrotome.  The  patient  is  then  placed  in  the  lithotomy 
position,  a  grooved  staff  is  introduced,  and,  with  a  long,  straight  knife  entered 
one  inch  in  front  of  the  anus,  the  membranous  urethra  is  punctured,  the  back 
of  the  knife  being  towards  the  rectum.  The  incision  is  slightly  enlarged  for- 
ward, to  permit  the  introduction  of  the  index  finger.  If  the  staff  is  not  fully 
exposed,  a  somewhat  dull  though  pointed  knife  is  introduced  along  the  finger, 
and  the  tissue  still  remaining  between  the  tip  of  the  finger  and  the  groove  is 
cleared  away.  If  a  sharp  knife  is  used,  there  is  danger  of  making  the  incision 
unnecessarily  large  or  of  cutting  the  finger.  The  incision  is  planned  first  to  fit 
the  finger  and  afterwards  the  drainage-tube.    When  the  groove  of  the  staff  is 


STRICTURE  OF  THE  URETHRA  285 

felt,  a  probe-tipped  gorget  is  slid  along  it,  the  staff  is  removed,  and  a  drainage- 
tube  is  passed  along  the  concavity  of  the  gorget  into  the  bladder.  This  tube 
drains  the  bladder  directly,  giving  the  urethra  physiological  rest.  It  is. retained 
seven  to  ten  days;  after  the  second  day  it  is  taken  out  and  cleansed  daily,  and 
the  bladder  is  irrigated  twice  daily  with  a  1  to  10,000  or  1  to  5000  subhmate 
solution. 

This  operation  possesses  the  advantage  of  preventing  the  freshly  cut  stricture 
from  being  irritated  by  the  urine.  Since  contact  with  urine  is  an  essential 
factor  in  the  production  of  organic  stricture,  such  a  diversion  of  the  stream 
during  attempts  at  radical  cure  is  worthy  of  consideration  whenever  resilient, 
nodular,  or  traumatic  anterior  strictures  are  cut,  or  whenever  the  coarctation 
is  complicated  by  fistulse;  physiological  rest  is  thus  obtained  for  the  whole 
region,  and  the  inflammatory  products  in  the  wall  of  the  urethra  are  allowed 
to  undergo  fatty  degeneration  and  absorption. 

Harrison  particularly  recommends  his  operation  in  cicatricial,  contractile,  and 
relapsing  strictures  seated  in  the  deeper  part  of  the  urethra,  claiming  for  it 
the  following  advantages:  1.  It  is  applicable  to  the  worst  forms  of  urethral 
strictures.  2.  It  guards  against  rigors,  fevers,  and  the  complications  which 
tend  to  rise  from  these.  3.  It  tends  to  improve  permanently  the  condition  of 
the  stricture. 

Experience  has  shown  that  if  the  tissues  can  be  freed  from  every  source  of 
irritation  and  can  be  given  physiological  rest  for  a  long  period,  hardened  lymph 
will  disappear  and  the  urethral  walls  again  will  become  soft  and  yielding. 
Drainage  by  perineal  opening  is  the  only  way  in  which  complete  rest  can  be 
given  to  the  strictured  region. 

Perineal  Section. — This  operation  is  reserved  for  strictures  through  which 
the  smallest  instrument  cannot  be  made  to  pass.  Such  strictures,  whether 
gonorrhoeal  or  traumatic,  are  usually  deeply  seated,  and  are  approached  through 
the  perineum. 

A  special  hooked  staff  (Wheelhouse's)  is  required,  in  addition  to  a  probe- 
tipped  gorget,  scalpel,  forceps,  needles,  etc.  The  patient  is  placed  in  the 
lithotomy  position,  and  the  staff  is  introduced  with  the  groove  towards  the 
floor  of  the  urethra,  its  hooked  extremity  being  brought  gently  into  contact  with 
the  stricture.  No  force  is  permissible,  since  the  urethra  in  these  cases  is 
readily  torn.  While  an  assistant  holds  the  staff  in  position,  an  incision  is  made 
in  the  perineum,  and  the  urethra  is  exposed,  and  is  opened  in  the  groove  of  the 
staff,  not  upon  its  point,  thus  making  the  incision  at  least  a  quarter  of  an  inch 
in  front  of  the  stricture,  since  the  groove,  is  not  continued  to  the  hook-shaped 
extremity  of  the  staff.  Through  the  edges  of  the  urethral  incision  are  passed 
by  means  of  curved  needles  stout  silk  threads,  one  on  each  side,  forming  loop^s, 
by  drawing  on  which  the  urethral  walls  are  retracted.  The  staff  is  gently  with- 
drawn until  the  button  point  appears  in  the  wound.  It  is  then  turned  around 
so  that  the  groove  faces  the  roof,  and  the  button  is  hooked  in  the  upper  angle 
of  the  open  urethra."  The  urethra  is  now  stretched  open  at  three  points  just 
in  front  of  the  stricture.  The  button  on  the  staff,  however,  is  often  in  the  way, 
and,  if  so,  this  instrument  should  be  withdrawn.  With  the  anterior  surface  of 
the  stricture  thus  exposed,  the  narrow  opening  through  it  is  often  seen,  and  a 


286  GENITO-URINARY  SURGERY 

probe-pointed  director  is  passed  without  difficulty.  Even  if  warty  growths  or 
granulations  conceal  the  position  of  the  narrowed  channel,  careful  probing  with 
the  director  usually  results  in  the  ready  passage  of  the  latter  into  ihe  bladder. 
The  groove  of  the  director  is  then  turned  downward,  and  along  it  the  whole 
length  of  the  stricture  is  carefully  and  fully  divided,  this  part  of  the  operation 
being  completed  by  running  a  straight  probe-pointed  bistoury  along  the  groove 
to  insure  the  cutting  of  every  band.  Teale's  gorget  is  now  passed  along  the 
groove  of  the  director  into  the  bladder,  and  the  director  is  withdrawn.  The 
object  of  the  gorget  is  to  facilitate  the  introduction  of  catheters  into  the  bladder, 
at  times  a  most  difficult  procedure  after  perineal  section.  A  full-sized  soft 
rubber  catheter  is  passed  from  the  meatus  into  the  bladder,  the  gorget  is  with- 
drawn, and  the  catheter  is  fastened  in  the  urethra.  After  three  or  four  days 
the  catheter  is  removed.  Sounds  are  then  passed  every  third  day,  until  the 
wound  in  the  perineum  is  healed,  and  after  that  from  time  to  cime  to  prevent 
recontraction. 

If  the  probe-pointed  director  does  not  find  the  opening  through  the  stricture, 
the  operation  must  be  continued  by  dissection  until  the  urethra  is  fairly  opened. 
If  the  bladder  contains  urine,  pressure  on  the  hypogastrium,  or  bimanual 
pressure,  one  hand  being  placed  on  the  abdomen  and  a  finger  of  the  other  in 
the  rectum,  will  often  cause  the  expulsion  of  some  urine,  and  thus  show  the 
opening  through  the  stricture.  The  use  of  very  hot  water  will  sometimes  be  of 
service  by  emphasizing  the  difference  in  color  between  the  surrounding  parts 
and  the  urethra,  the  latter  being  much  paler. 

The  operation  requires  a  good  light,  and  often  much  patience. 
Retrograde  Catheterization. — When  all  guides  fail,  and  when  aher  peri- 
neal section  the  proximal  end  of  the  urethra  cannot  be  found,  as  in  cases  of 
traumatic  stricture  with  practical  obliteration  of  the  canal,  a  suprapubic  cys- 
totomy and  retrograde  catheterization  are  indicated.  The  slight  additional  risk 
is  far  outweighed  by  the  advantages  to  the  patient  of  having  even  an  imperfect 
restoration  of  the  urethral  canal. 

In  performing  retrograde  catheterization  the  suprapubic  opening  into  the 
bladder  is  made  sufficiently  large  to  admit  the  finger;  guided  by  the  latter, 
which  can  readily  feel  the  vesical  orifice  of  the  urethra,  a  steel  sound  or  a  silver 
catheter  is  introduced  from  behind  forward  till  its  tip  becomes  apparent  through 
the  perineal  opening.  When  the  belly  is  prominent  it  may  be  difficult  to  pass 
an  ordinary  sound,  by  way  of  the  small  vesical  opening,  into  and  through 
the  prostatic  and  membranous  portions  of  the  urethra.  To  obviate  this  difficulty 
Guyon  has  suggested  an  instrument  with  a  longer  or  more  complete  curve; 
in  the  absence  of  this,  a  gum  catheter,  provided  with  a  stylet  and  with  the 
required  curve  given  it  may  be  employed.  As  soon  as  the  tip  is  freely  exposed 
through  the  perineal  wound,  a  soft  catheter,  the  end  of  which  has  been  cut 
off,  is  slipped  over  it;  on  withdrawing  the  sound  this  catheter  is  carried  from 
the  perineum  through  the  suprapubic  opening.  A  sound  having  been  passed 
from  the  meatus  to  the  perineal  wound,  the  other  end  of  the  soft  catheter  is 
forcibly  pushed  over  its  tip  and  is  drawn  forward  till  it  projects  from  the 
meatus;  or  a  catheter  may  he  passed  in  from  the  meatus  in  the  same  manner 
as  in  external  urethrotomy.    The  tube  is  left  in  place  for  from  five  to  seven  days. 


STRICTURE  OF  THE   JRETHRA  287 

Excision. — The  resection  of  the  strictured  part  of  the  urethra  requires  free 
incision,  not  only  for  the  removal  of  the  strictured  area,  but  for  the  mobilization 
of  sufficient  of  the  remaining  urethra  to  permit  suture  of  the  ends.  It  is  a 
difficult  operation,  and  is  only  indicated  in  traumatic  strictures,  and  after  the 
failure  of  simpler  measures.  The  transplantation  of  epithelium  may  be  neces- 
sary in  some  cases. 

Stout  has  advocated  the  removal  of  the  fibrous  tissue  surrounding  the  canal 
without  the  actual  opening  of  the  urethra.  He  reports  good  results  from  the 
procedure. 

SUMMARY    OF   TREATMENT 

1.  Gradual  dilatation  is  indicated  as  the  treatment  of  choice  in  all  recent, 
soft,  or  dilatable  strictures  found  in  any  part  of  the  urethra,  without  regard 
to  the  calibre  of  such  strictures. 

2.  Continuous  dilatation  is  indicated  in  uncomplicated  strictures  which 
are  so  tight  that  no  instrument  larger  than  a  filiform  can  be  made  to  pass. 
This  continuous  dilatation  is  practised  till  a  small  metal  or  woven  instrument 
can  be  introduced — No.  12  to  No.  16  F.  Then  the  normal  calibre  of  the 
urethra  is  restored  by  gradual  dilatation  or  by  cutting,  in  accordance  with  the 
nature  and  the  clinical  behavior  of  the  stricture. 

3.  Internal  urethrotomy  is  indicated  in  all  fibrous,  irritable,  and  resilient 
strictures  anterior  to  the  bulbomembranous  juncture.  Narrowings  at  or  near  the 
meatus  should  be  treated  by  the  knife  whenever  it  is  apparent  that  they  are 
responsible  for  definite  symptoms.  The  division  is  here  made  on  the  floor  of 
the  urethra.    All  other  anterior  strictures  are  divided  along  the  rooj. 

4.  External  perineal  urethrotomy  is  indicated  in  all  fibrous,  resilient,  or 
irritable  strictures  situated  at  or  behind  the  bulbomembranous  juncture. 

5.  Combined  internal  and  external  urethrotomy  is  indicated  in  the  treat- 
ment of  anterior  strictures  which  are  unusually  dense  or  nodular  or  whicii  are 
complicated  by  fistulae. 

6.  Perineal  section,  or  external  perineal  urethrotomy  without  a  guide,  is 
indicated  in  the  treatment  of  impassable  stricture  of  the  deep  urethra.  When  the 
proximal  urethral  end  cannot  be  found,  suprapubic  cystotomy  and  retrograde 
catheterization  are  in  order. 

7.  Excision  is  indicated  in  cases  of  impermeable  stricture,  nodular  or  fibroid, 
where  there  has  been  complete  destruction  of  mucous  membrane.  When  so 
much  tissue  is  removed  that  it  is  impossible  to  bring  the  divided  urethral  ends 
in  apposition,  transplantation  of  mucous  membrane  is  indicated. 

STRICTURE  OF  THE  FEMALE  URETHRA 
Stricture  of  the  female  urethra  is  comparatively  rare.  In  cause  and  symp- 
toms it  corresponds  with  the  like  condition  of  the  male  urethra.  It  may  be 
congenital  or  acquired,  and  the  acquired  stricture  may  be  spasmodic,  inflamma- 
tory, or  organic.  The  congenital  stricture  is,  as  in  the  case  of  the  male,  usually 
placed  at  or  near  the  urinary  meatus. 

Spasmodic  stricture,  that  due  to  muscular  spasm,  is  more  freouent  than  in 
the  male.    This  is  doubtless  owing  to  the  greater  reflex  susceptibility  of  women. 


288  GENITO-URINARY  SURGERY 

Familiar  examples  are  afforded  by  retention  of  urine  due  to  fright,  exhaustion,, 
exposure,  urethritis,  caruncles,  etc. 

Inflammatory  stricture — i.e.,  encroachment  on  the  urethral  calibre  by 
acute  inflammatory  swelling — probably  never  becomes  sufficiently  marked  to 
produce  retention,  this  when  it  occurs  being  due  to  spasm  reflexly  excited  from 
the  hypersemic  and  hyperaesthetic  areas . 

Organic  stricture  is  due  to  trauma,  commonly  inflicted  during  childbirth, 
or  to  inflammation,  usually  gonorrhoeal  in  nature,  but  is  sometimes  occasioned 
by  a  urethral  calculus,  or  by  the  virus  of  chancre  or  chancroid,  or  by  irritating 
applications.  The  urethral  narrowing  is  due  to  the  contraction  of  the  fibrous 
tissue  which  has  been  deposited  in  the  walls  of  the  canal  as  an  inflammatory 
infiltrate  and  which  has  subsequently  become  organized.  Hermann  states  that 
in  old  women  there  is  found  stricture  due  to  general  fibroid  thickening  of  the 
urethra,  occurring  without  any  history  of  gonorrhoea  or  other  discernible  cause. 
The  seats  of  narrowing  are  oftenest  at  or  near  the  meatus  and  near  the  neck 
of  the  bladder.  The  stricture  is  usually  single,  and  frequently  occasions  so  little 
inconvenience  that  its  presence  is  not  suspected  by  the  patient. 

Skene  states  that  organic  stricture  sometimes  occurs  at  the  juncture  of 
the  urethra  with  the  bladder,  and  that  even  though  it  be  of  large  calibre  it 
occasions  symptoms  out  of  all  proportion  to  the  amount  of  narrowing  it  pro- 
duces; this  is  probably  because  there  is  infiltration  of  the  vesical  sphincter  and 
interference  with  its  function.  Difficult  urination  and  retention  are  the  most 
characteristic  symptoms,  the  stricture  being  of  such  a  large  calibre  that  it  may 
escape  detection  by  the  bulbous  bougie. 

Symptoms. — The  symptoms  of  stricture, in  women  are  frequent  urination, 
dribbling  after  the  act,  the  passage  of  an  irregular  stream,  and  often  urethral 
discharge. 

At  times  the  only  symptom  is  an  occasional  attack  of  retention  of  urine 
occasioned  by  slight  causes,  such  as  exposure  or  fatigue,  and  usually  ascribed  to 
muscular  spasm.  Though  the  spasmodic  element  is  in  these  cases  always  the 
exciting  cause  of  the  retention,  the  predisposing  cause  will  occasionally  be  found 
to  be  a  urethral  stricture  of  large  calibre. 

Difficult  urination  and  sometimes  retention  particularly  characterize  stricture 
at  the  juncture  of  the  urethra  and  the  bladder. 

Diagnosis, — The  diagnosis  is  made  by  careful  examination  of  the  floor  of 
the  urethra  by  means  of  a  finger  introduced  into  the  vagina  and  by  the  passage 
of  bulbous  bougies.  By  the  vaginal  touch  cicatricial  induration  of  any  part  of 
the  urethra,  if  marked,  can  be  found.  This  is  the  most  reliable  method  of 
detecting  the  stricture  of  the  neck  of  the  bladder,  described  by  Skene,  since 
the  narrowing  may  be  so  slight  that  a  comparatively  large  instrument  may 
pass  through  readily. 

In  passing  the  bulbous  bougie  it  must  be  borne  in  mind  that  the  urethra 
in  women  has  two  points  of  physiological  narrowing, — i.e.,  the  meatus  and  the 
neck  of  the  bladder;  the  canal  between  these  points  admits  of  wide  dilatation. 
If  a  very  large  bulbous  bougie  is  introduced,  the  resistance  offered  to  the 
inward  or  outward  passage  of  the  instrument  by  the  seats  of  normal  narrowing 
might  readily  be  mistaken  for  that  due  to  organic  stricture. 


STRICTURE  OF  THE  URETHRA  289 

Prognosis. — The  prognosis  of  stricture  of  the  urethra  in  women  is  much 
better  than  is  the  case  with  men.  The  narrowing  rarely  reaches  such  a  degree 
that  the  function  of  micturition  is  greatly  interfered  with,  and  hence  the  train 
of  vesical,  renal,  and  general  vascular  changes  which  ultimately  result  fatally 
is  rarely  inaugurated.  In  exceptional  cases  when  the  urethral  calibre  is  markedly 
encroached  on,  and  the  condition  is  unrelieved,  the  prognosis  is  the  same  as 
for  men. 

Treatment. — Congenital  or  inflammatory  narrowings  of  the  meatus  should 
be  cut  freely,  the  normal  calibre  being  maintained  by  the  use  of  a  meatus  bougie. 
The  directions  given  for  the  performance  of  meatotomy  in  the  male  obtain  in 
these  cases.  Soft,  recent,  dilatable  strictures  are  gradually  cured  by  short 
straight  steel  sounds.  Dense,  traumatic,  nodular,  irritable,  or  resilient  strictures 
are  treated  by  internal  urethrotomy.  When  the  urethra  is  totally  obliterated  at 
one  point  the  propriety  of  excision  and  of  mucous  membrane  transplantation 
may  be  considered. 


1^ 


CHAPTER  XIV 

SURGERY  OF  THE  SCROTUM 

ANATOMY,  DEFORMITIES,  INJURIES  AND  WOUNDS.     (EDEMA, 
EMPHYSEMA,  CUTANEOUS  AFFECTIONS.     GANGRENE. 
ELEPHANTIASIS.     TUMORS. 

ANATOMY 

The  scrotum  is  a  pouch  of  skin  and  fibromuscular  tissue,  the  dartos. 

The  skin  is  provided  with  numerous  sebaceous  folHcles  and  a  small  number 
of  hairs,  and  after  maturity  becomes  pigmented.  It  generally  exhibits  folds 
or  rugae  passing  at  right  angles  to  the  median  raphe. 

The  dartos  is  composed  of  connective  tissue  and  smooth  muscular  fibreS: 
It  is  continuous  with  the  superficial  fascia  of  the  groin  and  perineum,  and  forms 
at  a  position  corresponding  to  the  raphe  an  incomplete  septum  partially  separat- 
ing the  two  sides.  The  dartos  is  closely  attached  to  the  skin,  and  is  abundantly 
supplied  with  blood-vessels.  By  its  contraction  it  draws  the  skin  of  the  scrotum 
into  folds  and  holds  the  testicles  up  near  the  position  of  the  external  rings. 
The  contraction  of  this  muscular  tissue  is  occasioned  by  sexual  excitement,  by 
cold,  or  by  mechanical  stimuli. 

Beneath  the  dartos  there  is  a  layer  of  loose  cellular  tissue  on  which  the 
skin  and  dartos  are  freely  movable,  and  into  the  meshes  of  which  blood  effusions 
or  dropsies  may  readily  occur. 

The  blood-supply  to  the  scrotum  is  derived  from  the  external  pudic  arteries, 
the  superficial  branch  of  the  internal  pudic  and  the  cremasteric  arteries.  The 
lymphatics  are  received  by  the  inguinal  nodes. 

The  points  of  practical  value  to  be  gathered  from  a  consideration  of  the 
anatomy  of  the  scrotum  are:  (1)  from  the  close  attachment  of  the  dartos  to 
the  skin,  the  latter  when  wounded  is  liable  to  be  inverted,  thus  making  perfect 
apposition  difficult  in  suturing  incisions  of  this  portion  of  the  body;  (2)  in 
consequence  of  the  loose  texture  of  the  cellular  tissue  lying  within  the  dartos 
and  the  abundant  vascularity  cf  the  scrotum,  bleeding  incident  to  traumatism 
is  free  and  is  likely  to  form  large  accumulations;  (3)  on  account  of  this  same 
arrangement,  oedema  of  the  scrotum  is  pronounced  from  comparatively  slight 
causes,  and  septic  infection  spreads  quickly  and  sloughs  widely. 

Deformities 
Congenital  deformities  of  the  scrotum  unaccompanied  by  malformation  of 
the  penis  or  malposition  of  the  testicles  are  practically  unknown.  With  hypo- 
spadia and  pseudohermaphroditism  the  raphe  becomes  converted  into  a  distinct 
cleft,  dividing  the  scrotum  into  two  halves,  much  like  the  labia  majora.  When 
there  is  an  undescended  testicle  the  scrotum  usually  does  not  develop  on  the 
affected  side,  thus  producing  some  asymmetry.  At  times  adhesions  binding 
together  the  scrotum  and  the  penis  are  noted  at  birth. 
290 


SURGERY  OF  THE  SCROTUM  291 

DISEASES  OF  THE  SCROTUM 

Injuries  of  the  Scrotum. — Contusions  may  be  extensive  without  involve-- 
ment  of  the  testicles,  these  organs  readily  slipping  from  the  direct  line  of 
pressure.  Such  injuries  are  followed  by  rapid  swelling,  extensive  sub- 
cutaneous blood  effusions,  and  intense  discoloration.  They  should  be  treated 
by  thorough  preliminary  cleansing  of  the  skin,  rest,  pressure,  and  the  application 
of  evaporating  lotions.  Under  such  treatment  suppuration  does  not  take  place. 
When  the  skin  is  not  clean,  and  especially  when  it  becomes  abraded,  extensive 
and  obstinate  suppuration  may  occur. 

Wounds  of  the  scrotum  are  treated  upon  the  general  principles  applicable 
to  wounds  of  other  portions  of  the  body.  Haemostasis  should  be  complete 
before  closure,  since  the  vessels  are  without  support,  and  if  not  secured  may 
bleed  into  the  loose  cellular  tissue,  forming  large  accumulations  of  blood. 

At  the  time  of  suture  the  borders  of  the  wound  must  be  so  approximated 
that  the  tendency  to  inversion  of  the  skin  shall  be  overcome.  Catgut,  silk,  and 
horse-hair  are  the  best  suture  materials;  a  continuous  glover's  suture  applied 
close  to  the  wound  edges  answers  well. 

After  closure  and  aseptic  dressing,  the  scrotum  should  be  supported  by 
means  of  a  suspensory  bandage,  or  jock-strap,  or  crossed  of  the  perineum  roller. 

CEdema  of  the  scrotum  may  be  an  expression  of  general  anasarca  due  to 
lesions  of  the  heart  and  kidneys,  in  which  case  it  is  usually  pronounced,  and  in 
some  instances  first  calls  attention  to  the  central  lesion,  or  it  may  be  due  to 
inflammation  of  the  overlying  skin  or  of  the  testicles,  local  interference  with 
circulation,  as  from  lymphadenitis  of  the  groin,  infiltration  of  urine,  rupture 
of  a  hydrocele,  or  septic  infection.  Simple  oedema  sometimes  threatens  the 
vitality  of  the  part ;  in  this  case  tension  is  relieved  by  multiple  needle-punctures 
made  under  the  strictest  antiseptic  precautions.  Inflammatory  oedema  is  treated 
by  attacking  the  cause  of  inflammation, — evacuating  the  extravasated  urine  by 
incisions,  for  instance,  or  opening  abscesses. 

Emphysema  may  be  due  to  entrance  of  air  into  the  loose  cellular  tissues 
through  a  wound,  such  as  that  produced  by  a  trocar,  or  to  the  escape  of  air  or 
gas  from  a  hollow  viscus  remote  from  the  scrotum;  as,  for  instance,  when  the 
stomach  and  intestines  are  opened,  occasioning  general  emphysema.  More 
commonly  it  is  due  to  gas,  the  result  of  fermentation  and  putrefaction  in  locOy 
and  this  in  a  measure  is  an  index  to  the  extent  of  sloughing  or  gangrene  going 
on  beneath  the  surface. 

The  treatment  of  emphysema  when  it  is  simply  aerial  and  is  not  a  symptom 
of  extensive  tissue-destruction  should  be  conservative.  When  it  is  due  to  the 
gas  of  decomposition,  free  incisions  and  vigorous  disinfection  are  required. 

The  cutaneous  affections  of  the  scrotum  are  practically  those  of  other 
skin  surfaces  of  the  body,  and  are  amenable  to  the  same  treatment.  It  should 
be  borne  in-  mind,  however,  that  the  skin  of  the  scrotum  is  extremely  sensitive 
to  irritating  applications,  such  as  tincture  of  iodine,  which  if  painted  over  this 
region  may  cause  intense  pain  for  many  hours. 

There  are  certain  skin  eruptions  which  develop  on  the  scrotum  with  great 
frequency.    Among  these  are  erythema,  intertrigo,  eczema,  pruritus,  and  pedi- 


292  GEXITO-URIXARY  SURGERY 

culosis.  ]More  rarely  molluscum  contagiosum,  sebaceous  cj^sts,  pityriasis,  eczema 
marginatum  and  scabies  are  observed. 

Erythema  intertrigo  is  very  frequently  observed  in  children  and  in  fat, 
soft  men.  especially  those  who  are  rheumatic  in. tendency  or  are  uncleanly  in 
their  habits  and  who  are  given  to  exercise,  such  as  walking,  which  occasions 
friction  between  moist  surfaces. 

The  treatment  consists  in  thorough  cleanliness  and  the  interposition  of  a 
layer  of  soft  muslin  or  Imt  between  the  chafing  surfaces,  or,  better  still,  the 
application  of  a  suspensory  bandage,  made  of  thin  gauze.  The  parts  are  bathed 
in  weak  solutions  of  carbolic  acid  1  to  200  and  hydrastis  canadensis  1  to  20, 
after  which  they  are  carefully  dried  and  dusted  with  finely  powdered  zinc 
stearate  powder.  In  some  cases  ointments  give  better  results.  One  of  the  best 
is  that  of  resorcin  two  per  cent,  made  up  with  lanoHn  and  lard  equal  parts. 

Eczema  ma\'  develop  in  healthy  persons,  though  it  is  more  frequentty 
observed  in  association  with  the  gouty  or  rheumatic  diathesis,  sometimes  in 
connection  with  diabetes.  It  may  appear  in  almost  any  of  its  various  forms, 
is  extremely  obstinate,  and  causes  intense  itching  and  burning.  There  are  fre- 
quentty  concomitant  swelling  of  the  whole  scrotum,  deepening  of  the  transverse 
rugse.  and  the  formation  of  raw  surfaces  from  which  there  exudes  an  offensive 
discharge. 

The  treatment  is  that  general!}'  applicable  to  this  disease. 

Among  the  most  useful  prescriptions  are  the  following: 

IJ   Zinci  oxidi, 

Zinci  carbonat.,  aaovi; 

Gh'cerini,  f3iv; 

Liquor,   calcis,   f^vi. 
M.  S. — Shake  well  before  apph-ing. 

This  should  be  dabbed  on  for  four  or  five  minutes.  In  chronic  cases  with 
thickening  the  following  may  be  applied  (Bulkley): 

B   Picis  liquidse,  3ii; 
Potassse  causticEe,  Si; 
AquEe  f5v. 

This  miay  be  used  as  an  antipruritic,  diluted  with  twent}^  to  thirty  parts  of 
water,  or  may  be  rubbed  directty  into  the  infiltration. 

An  excellent  powder  to  be  employed  during  the  day  is  the  following: 

B  Pulv.  am^'li.  3vi; 
Zinci  oxidi,  5iss; 
Pulv.  camphorae,  3ss; 
or 

B^  Thj-mol.  gr.  ii; 

Pulv.  zinci  stearat.,  3iv. 

Pityriasis. — Patients  with  delicate  skins  are  occasionally  annoyed  in  warm 
weather  by  a  light-bromide  discoloration  of  the  skin  of  the  thighs  and  scrotum, 
where  these  surfaces  are  continually  in  contact.  The  affection  is  further  attended 
by  considerable  itching  and  is  due  to  a  vegetable  parasite  inhabiting  the  upper 
layer  of  the  epidermis. 


SURGERY  OF  THE  SCROTUM  293 

After  washing  the  area  with  soap  and  drying  to  remove  grease  from  the 
scales  and  spores,  a  few  appUcations  of  sulphurous  acid  will  effect  cure. 

Eczema  marginatum  is  another  parasitic  disease,  frequenting  the  thighs, 
scrotum,  mons  veneris  and  buttocks.  This  affection  is  not  an  eczema,  but  a 
combination  of  herpes  tonsurans  and  intertrigo,  as  proved  by  Pick.  The  disease 
requires  friction,  moisture,  and  the  filaments  and  spores  of  the  tricophyton  of 
Malinster  for  development.  The  common  site,  therefore,  is  between  the  scrotum 
and  the  thigh.  The  lesion  appears  as  one  or  more  small  round  patches,  red, 
slightly  elevated,  and  itchy.  The  sequence  of  the  eruption  is  papule,  vesicle, 
excoriation,  and  crust.  The  lesion  spreads  eccentrically,  the  periphery  being 
sharply  demarcated,  characterizing  the  disease.  As  the  centre  heals  a  brownish 
discoloration  results  and  the  surface  is  studded  with  small  collections  of  scales. 
It  is  refractory  to  treatment,  and  recurrences  are  frequent,  springing  from  the 
circumference  of  the  area  first  affected,  necessitating  the  continuation  of  treat- 
ment after  the  disappearance  of  lesions.  The  best  parasiticide  lotion  is  bi- 
chloride of  mercury,  1  to  10,000  or  8000,  continuously  applied.  Pure  sulphurous 
acid  also  acts  well. 

Pruritus  is  most  frequently  observed  in  rheumatic  or  gouty  subjects. 
Though  often  associated  with  the  lesions  of  pediculi,  it  may  develop  indepen- 
dently of  these. 

The  treatment  must  be  in  the  main  systemic,  though  the  local  antipruritic 
applications,  such  as  thymol,  tannic  acid,  tar,  camphor,  etc.,  are  serviceable. 
Prolonged  hot  bathing  of  the  parts  is  useful. 

Pediculosis  ultimately  excites  intense  pruritus,  though  it  is  often  not  de- 
tected for  a  long  time.  Careful  examination  of  the  scrotum  shows  the  parasites 
at  once.  They  appear  as  minute  scabs,  most  abundant  about  the  root  of  the 
penis.    The  ova  are  found  on  the  hairs. 

The  application  of  an  ointment  of  twenty  per  cent,  oleate  of  mercury  one 
part,  petrolatum  two  parts,  or  of  mercurial  ointment  one  part,  petrolatum 
three  parts,  rubbed  into  the  scrotum  every  night,  the  excess  being  wiped  off 
with  a  soft  towel  before  retiring,  and  the  whole  region  washed  with  soap  and 
hot  water  the  following  morning,  will  be  followed  by  cure  in  a  few  days. 

Tincture  of  cocculus  indicus  applied  freely  after  a  warm  bath  and  allowed 
to  dry  on  the  part  is  more  cleanly  and  is  efficacious. 

Molluscum  contagiosum  is  observed  mostly  in  children.  The  lesions  con- 
sist of  small,  waxy,  almost  spherical  tumors  or  cysts,  situated  in  the  superficial 
layers  of  the  skin.  They  are  sessile,  but  may  become  pedunculated  when  they 
have  existed  for  a  considerable  time  without  softening.  At  first  smooth  and 
round,  they  become  umbilicated,  exhibiting  a  small  black  spot  in  the  centre 
of  the  depression,  which  indicates  the  opening  into  the  follicle.  They  grow- 
slowly,  and  occasion  no  pain  unless  complicated  by  inflammation. 

They  may  disappear  spontaneously,  but  should  be  removed,  since  they  are 
contagious.  The  contents  of  the  cyst  may  be  squeezed  out  and  the  walls  touched 
with  pure  carbolic  acid.  Pedunculated  growths  should  be  snipped  off  and 
their  bases  cauterized. 


294 


GENITO-URINARY  SURGERY 


Steatomata  or  Sebaceous  cysts  have  not  the  waxy  appearance  of  mol- 
luscum,  nor  do  they  appear  in  childhood.  They  are  usually  single,  but  may  be 
multiple.  They  are  soft  and  doughy  in  consistence,  and  when  infected  break 
down  and  suppurate.  They  sometimes  attain  the  size  of  a  hen's  egg.  The 
thin  overlying  skin  becomes  adherent  in  inflammatory  cases.  Removal  of  the 
entire  sac  is  the  only  effective  treatment. 

Gangrene  of  the  Scrotum. — This  affection,  extremely  rare,  except  as  a 


r 


■ '^--N^ISW-^iirf^^ 


Fig.  150. — Elephantiasis  of  the  penis  and  scrcrtum,  showing  the  result  of  operation. 

complication  of  rupture  of  the  urethra  or  as  a  sequel  of  extensive  traumatism, 
has  been  attributed,  when  it  follows  inflammation  of  the  inguinal  nodes  or  opera- 
tion on  these  structures,  to  reflected  nerve  irritation,  but  is  more  probably  due 
to  infection  with  the  ordinary  pus  microbes. 

Among  the  causes  of  this  condition  are  included  urinary  infiltration,  erysipe- 
las, thrombosis,  embolism,  and  incidentally  influenza,  typhus  and  other  fevers, 
syphilis,  gonorrhoea,  diabetes,  prostatic  disease,  pediculi  pubis,  ergotism,  trau- 
matism (faulty  punctures  and  injections),  and  frost-bite. 


SURGERY  OF  THE  SCROTUM  295 

Even  though  the  testicles  be  completely  denuded,  they  will  ultimately  be 
covered  by  granulation-tissue  and  their  function  will  be  preserved. 

Treatment. — Scrotal  gangrene  should  be  treated  by  hot  antiseptic  fomenta- 
tions until  the  sloughs  separate.  The  testicle  should  then  be  covered  as  com- 
pletely as  possible  by  suturing  the  remaining  healthy  skin,  the  wound  being 
dressed  daily  until  complete  healing,  with  gauze  wrung  out  of  nonirritating 
lotions,  as  4  per  cent,  sodium  chloride.  When  due  to  urinary  infiltration — 
the  usual  cause — free  incisions,  and  direct  drainage  from  the  point  of  urethral 
rupture  are  indicated. 

Elephantiasis,  endemic  in  certain  countries,  is  rare  in  the  United  States. 
It  is  generally  supposed  to  be  due  to  the  stoppage  of  lymph-channels  by  the 
ova  of  the  filaria  sanguinis  hominis,  but  in  this  country  it  has  been  observed 
in  cases  in  which  the  parasite  was  not  present  in  the  blood,  and  the  obstruction 
to  the  flow  of  lymph  could  be  accounted  for  only  by  some  preceding  inflamma- 
tory condition,  such  as  recurrent  attacks  of  erysipelas  or  dermatitis,  or  cicatri- 
zation following  syphilitic  lesions  or  excision  of  the  inguinal  nodes. 

Prunner  states  that  the  disease  always  begins  in  the  form  of  a  hard,  kernel 
under  the  skin,  usually  at  the  bottom  of  the  left  side  of  the  scrotum.  This 
spreads  in  all  directions,  forming  a  diffuse,  hard,  thick,  wrinkled  skin  tumefac- 
tion (Fig.  150).  The  tumor  is  pyriform,  and  the  rough,  often  warty,  skin 
covering  it  is  likely  to  become  excoriated  from  the  irritation  of  the  urine.  The 
growth  may  attain  an  enormous  size,  weighing  as  much  as  two  hundred  pounds. 
It  is  commonly  associated  with  some  degree  of  elephantiasis  of  the  skin  of  the 
lower  extremities.       The  testicles,  however,  remain  unaffected. 

Treatment. — In  the  early  stages  galvanism  and  the  internal  administration 
of  potassium  iodide  may  be  serviceable.  When  the  tumor  attains  such  size 
as  to  be  inconvenient  from  its  weight,  complete  excision  of  all  the  diseased 
tissues  is  indicated.  This  operation  is  usually  bloody,  many  vessels  requiring 
ligation.  The  best  means  of  checking  hemorrhage  during  removal  is  to  transfix 
the 'tumor  at  its  base  with  long  pins,  and  to  apply  behind  these  transfixing 
pins  the  elastic  ligature.  The  fact  that  hernia  frequently  complicates  this 
affection  must  be  borne  in  mind  in  applying  these  transfixing  pins  and  securing 
the  elastic  band.  The  penis  and  testicles  are  first  freed,  then  all  the  diseased 
tissue  is  cut  away.  Even  though  the  testicles  are  entirely  denuded,  this  need 
not  occasion  anxiety,  since  they  will  be  covered  by  granulation-tissue. 

Tumors  of  the  Scrotum. — Epithelioma. — Aside  from  sebaceous  cysts, 
epithelioma  is  the  most  frequent  form  of  new  growth  observed  upon  the  scrotum. 
It  is  called  "  chimney-sweepers'  cancer,"  because  it  formerly  attacked  by  prefer- 
ence people  engaged  in  this  work.  In  recent  years  the  method  of  cleaning 
chimneys  has  changed,  and  the  name  is  no  longer  applicable. 

It  begins  as  an  indurated  wart,  which  becomes  excoriated  and  scabby  on  its 
surface;  this  wart  is  shortly  transformed  into  an  ulcer,  which  is  characterized 
by  hard,  raised  edges,  uneven  surface,  unhealthy  granulations,  and  the  exudation 
of  ichorous  pus.  It  is  sometimes  extremely  painful,  and  steadily  extends,  ulti- 
mately involving  the  inguinal  lymphatic  glands,  which  soften  and  ulcerate.    It 


296 


GENITO-URINARY  SURGERY 


is  stated  that  workers  in  coal-tar  are  especially  liable  to  this  form  of  disease 
(Fig.  151). 

Treatment. — The  treatment  consists  in  the  removal  of  the  indurated  tissues 
by  an  incision  carried  wide  of  the  diseased  area.  The  inguinal  lymph-nodes 
should  be  removed  at  the  same  time.  Thus  treated  early  in  the  course  of  the 
affection  the  prognosis  is  favorable. 

Fatty  tumors  are  at  times  observed;  they  are  of  importance  because  of 
their  intimate  connection  with  the  testicle.    Diagnosis  is  rarely  possible  without 


Fig.  151. — "Coal-tar  worker's  cancer"  of  the  scrotum. 

exploratory  incision,  because,  on  palpation,  they  feel  almost  precisely  as  does 
an  irreducible  omental  hernia.    Excision  is  the  only  treatment. 

Fibromata  are  rarely  observed.  They  are  freely  movable  under  the  skin. 
They  should  be  removed  as  soon  as  discovered,  since  in  their  development  they 
may  form  adhesions  to  the  testicle,  which  would  make  subsequent  operation 
without  injury  to  this  gland  extremely  difficult.  These  fibrous  tumors  some- 
times recur  after  removal. 

Gummata,  enchondromata,  osteomata,  and  cysts  are  occasionally 
observed. 


CHAPTER  XV 

'    SURGERY  OF  THE  TESTICLES 

ANATOMY 

By  the  testicular  parenchyma  the  spermatozoa  are  formed,  the  primary  func- 
tion of  these  organs.  They  also  have  an  internal  secretion  which  is  essential 
for  the  development  of  the  prostate  and  the  penis,  and  for  the  characteristic 
male  configuration,  hirsutes,  and  restless  combativeness.  Testicular  growth  and 
function  are  profoundly  influenced  by  the  thyroid,  the  pituitary,  the  pineal, 
and  the  suprarenal  glands. 

In  the  adult  the  testicles  are  suspended  in  the  scrotum  by  the  spermatic 
cords. 

Developed  within  the  abdomen,  during  the  latter  half  of  fcetal  Hfe, .  they 
descend  into  the  scrotum,  being  drawn  down  by  a  musculo-fibrous  cord — the 
gubernaculum  testis — which  is  attached  above  to  the  base  of  the  epididymis 
and  below  to  the  scrotum.  Lockwood  states  that  at  the  sixth  to  the  eighth 
month  of  intra-uterine  life  many  of  the  lower  fibres  extend  into  Scarpa's  tri- 
angle and  the  perineum;  this  may  explain  the  occasional  presence  of  the 
testicle  in  these  regions. 

The  testis  is  a  gland  of  oval  form;  it  is  hung  obliquely  in  the  scrotum,  the 
upper  extremity  being  directed  somewhat  forward.  (Figs.  152,  153.)  It  has 
flattened  sides  and  is  of  variable  dimensions,  but  commonly  is  one  and  a  half 
inches  long,  an  inch  broad,  and  an  inch  and  a  quarter  from  behind  forward. 
The  weight  of  each  gland  is  from  three-quarters  of  an  ounce  to  one  ounce,  and 
the  left  is  somewhat  larger  than  the  right. 

The  tunica  vaginalis  is  derived  from  the  peritoneum  during  the  descent  of 
the  testicle  in  fcetal  life.  It  is  the  serous  covering  of  the  testis,  and  is  com- 
posed of  two  layers, — an  inner  visceral  and  an  outer  parietal.  The  inner  vis- 
ceral portion  forms  a  close  investment  for  the  testicle  and  epididymis,  while 
the  outer  parietal  portion  is  a  loose  sac  investing  the  testis  and  extending  for 
some  distance  up  the  cord.  The  true  capsule  of  the  testicle  is  the  tunica  albu- 
ginea.  This  is  a  tough  covering,  composed  of  interlacing  bundles  of  white 
fibrous  tissue.  It  is  covered  everywhere  by  the  tunica  vaginalis  (Plate  VIII), 
except  at  the  points  of  attachment  to  the  epididymis.  At  the  posterior  portion 
of  the  gland  the  tunica  albuginea  is  inverted  into  the  interior  and  forms  an 
imperfect  septum, — the  mediastinum.  It  extends  from  the  upper  nearly  to 
the  lower  border  of  the  gland;  from  it  numerous  trabeculae  radiate  towards  the 
surface  of  the  testicle,  dividing  the  interior  of  the  latter  into  many  spaces, 
conical  in  shape,  with  their  bases  towards  the  surface.  The  trabeculae  serve 
to  maintain  the  general  shape  of  the  organ,  to  convey  the  numerous  blood- 
vessels that  ramify  in  its  interior,  and  act  as  supports  to  the  glandular  structure 
of  the  testicle,  which  is  made  up  of  lobules. 

297 


298 


GENITO-URINARY  SURGERY 


These  lobules,  in  accordance  with  the  arrangement  of  the  trabeculae,  which 
m  each  testicle  have  been  variously  estimated  at  from  one  hundred  and  fifty  to 
four  hundred  in  number,  are  pyramidal  in  shape.  (Fig.  154.)  According  to 
their  size,  the  glandular  lobules  are  made  up  of  three  or  more  convoluted  semi- 
niferous tubes,  variously  estimated  as  being  from  two  to  sixteen  feet  in  length. 
It  is  in  these  tubes  that  the  spermatoblasts  which  subsequently  become  con- 
verted into  spermatozoa  are  formed.     The  tubes  begin  in  caecal  extremities,  or 


Fig.  152. 


Fir,.  153. 


Fig.  1S2. — Left  testis.  1,  outer  surface;  2,  2,  antero-infenor  surface;  3, 
postero-superior  surface;  4,  upper  extremity,  with  hydatid  of  Morgagni;  6,  postero- 
inferior  extremity;  7,  epididymis;  8,  its  head;  9,  its  tail;  10,  10,  10,  deferent  canal 
11,  11,  spermatic  artery;  12,  anterior  spermatic  veins  surrounding  the  artery; 
13,  posterior  spermatic  veins. 

Fig.    153. — Left    testis.      1,    inner   surface;    2,    antero-inferior    surface;    3, 
upper    extremity    surmounted    by    Morgagni's    hydatid;    4,    posterior -infero    sur- 
face; 5,  head  of  the  epididymis;  6,  tail;  7,  7,  deferent  canal  accompanied  by  the 
deferential  artery;   8,   8,  spermatic  artery;  9,  anterior  spermatic  plexus;    10,  pos- 
terior spermatic  plexus.     (Sappey.) 

intercommunicate  with  other  tubes;  as  they  approach  the  apices  of  the  cones 
they  become  much  less  convoluted,  finally  uniting  to  form  twenty  or  thirty  ducts, 
which  from  their  straight  course  are  named  the  vasa  recta.  These  vessels  pass 
upward  and  backward,  penetrate  the  mediastinum,  and  form  an  anastomotic 
net-work  made  up  of  channels  in  the  fibrous  tissue  without  proper  walls  and 
termed  the  rete  testis.  These  channels  terminate  at  the  upper  end  of  the 
mediastinum  in  twelve  to  twenty  ducts,  called  the  vasa  efferentia,  which  per- 


PLATE  VIII. 


Showing  the  relations  and  coverirgs  of  the  testicle  and  epididymis.    (Testut.) 
P.  Penis,     t/.  Urethra.     C.  Spermatic  cord.    £.  Epididymis.     T.  Testicle. 


SURGERY  OF  THE  TESTICLES 


299 


forate  the  tunica  albuginea,  and  convey  the  seminal  secretion  to  the  upper  part 
of  the  epididymis;  they  are  at  first  straight,  but  subsequently  become  enlarged 
and  convoluted,  forming  the  coni  vasculosi,  which  collectively  constitute  the 
globus  major,  or  upper  enlargement  of  the  epididymis  (Fig.  155).  The  efferent 
vessels  finally  open  into  a  single  duct,  the  canal  of  the  epididymis,  which 
constitutes  by  its  convolutions  the  body  and  globus  minor  of  the  epididymis, 
measuring  in  its  natural  state  about  three  inches  in  length,  but  when  un- 
ravelled nearly  twenty  feet.  The  convolutions  are  held  together  by  areolar 
tissue;  the  interior  of  the  canal  is  lined  by  columnar  ciliated  epithelium. 

In  foetal  life  the  head  of  the  epididymis,  its  canal,  the  vas  deferens,  and 
the  ejaculatory  duct  are  formed  from  the  canals  and  ducts  of  the  Wolffian  body. 
The  vas  aberrans  is  formed  from  the  same  body,  persisting  as  a  canal,  running 
upward  from  the  lower  part  of  the  epididymis  or  the  commencement  of  the 


Fig.  154. 


Fig.  155. 


Fig.  154. — The  lobules  of  the  testis,  the  rate  testis,  the  efferent  vessels,  and  the 
epididymis.  1,  1,  1,  seminiferous  lobules  of  the  testis;  2,  rete  testis;  3,  3,  efiferent  canals,  the 
com  vasculosi,  collectively  forming  the  head  of  the  epididymis;  4,  4,  4,  canal  of  the  epi- 
didymis; 5,  vas  aberrans;  6,  its  entrance  into  the  epididymis;  7,  origin  of  the  convoluted 
portion  of  the  vas  deferens;  8,  vas  deferens. 

Fig.  155. — 1,  efferent  canal,  showing  its  comparatively  large  calibre  and  straight 
direction;  2,  beginning  convolutions;  3,  cone  formed  by  the  convolutions,  aiconus  vascu- 
losus;  4,  opening  of  the  convoluted  tube  into  the  canal  of  the  epididymis;  5,  5,  the  canal  of 
the  epididymis  unravelled.     (Sappey.) 

vas.  The  pedunculated  body  called  the  hydatid  of  Morgagni,  found  between 
the  upper  portion  of  the  testis  and  the  globus  major,  is  a  remnant  of  the  duct 
of  Miiller. 

The  continuation  of  the  convoluted  canal  of  the  epididymis  is  known  as 
the  vas  deferens;  it  ascends  at  the  back  of  the  testicle  as  part  of  the  spermatic 
cord.  Entering  the  abdomen  through  the  internal  abdominal  ring,  it  descends  to 
the  pelvis,  passing  forward  and  inward  across  the  external  iliac  vessels.  On 
reaching  the  bladder  it  passes  downward  to  the  inner  side  of  the  ureter,  and 
at  its  base  is  joined  by  a  duct  from  the  seminal  vesicles  to  form  the  ejaculatory 
duct.  The  vas  in  the  beginning  of  its  course  is  convoluted,  but  for  the  greater 
part  is  uniformly  cylindrical,  and  easily  recognizable  from  the  rest  of  the  cord 
by  its  dense  hard  feeling;  when  it  reaches  the  base  of  the  bladder  it  becomes 


300  GENITO-URINARY  SURGERY 

markedly  ampullated.  It  is  provided  with  an  external  cellular  coat,  a  muscular 
coat,  and  an  inner  mucous  membrane,  the  latter  covered  with  columnar  epi- 
thelium. 

The  seminal  vesicles  are  pouches  placed  between  the  bladder  and  the  rectum. 
They  are  pyramidal  in  shape,  with  their  bases  directed  backward,  and,  although 
they  are  of  very  variable  size  and  shape  in  different  individuals  and  often  on 
the.  two  sides,  they  average  about  two  and  a  half  inches  in  length  and  half  an 
inch  in  breadth.  They  lie  in  direct  contact  with  the  base  of  the  bladder, 
extending  from  the  entrance  of  the  ureter  to  the  base  of  the  prostate  gland, 
and  are  separated  from  the 'rectum  by  the  recto-vesical  fascia.  Each  seminal 
vesicle  consists  of  an  irregular  tortuous  tube,  sometimes  giving  off  in  its  course 
several  blind  pouches,  which  are  connected  by  fibrous  tissue.  At  its  lower  ex- 
tremity this  tube  becomes  narrowed  into  a  straight  duct,  which  joins  the  vas 
deferens  of  the  corresponding  side,  to  form  the  ejaculatory  duct. 

The  ejaculatory  ducts  are  about  three-quarters  of  an  inch  long.  They 
pass  forward  and  upward  from  the  base  of  the  prostate  along  the  side  of  the 
prostatic  sinus,  and  terminate  in  slits  placed  at  the  lateral  margins  of  this  sinus. 
The  vesicles  and  ducts  are  provided  with  an  external  fibro-cellular,  a  middle 
muscular,  and  an  internal  mucous  layer;  the  epithelium  is  columnar. 

ANOMALIES  OF  THE  TESTICLE. 

f  f  Excess  Poh^orchism. 

1  in  number.  j     '  '  j  Absence,  anorchism. 

Anomalies   of      I  Dpfiripnrv  1    17       •  u- 

J  { uenciency,  [  Fusion,  sj'norchism. 

development.  .  tt  xj         *       u 

I  In  size.  /Excess.  Hypertrophy. 

Deficiency.  Arrested  development. 

Cryptorchidism  (lying  in  some  part 
of  the  normal  course). 
Anomalies  of  migration  i      Ectopy  (lying  outside  of  the  normal 

or  position.  course) 

.  .        .       ,  /Inversion. 

Malposition  in  the  scrotum.  <  ^^ 
I  I  Reversion. 

(Modified  from  Monod  and  Terrillon.) 
Anomalies   of  Number 

1.  Polyorchism. — With  the  exception  of  the  case  reported  by  Blasius,  there 
seems  to  be  no  well-authenticated  record  of  supernumerary  testis.  Cases  are 
frequently  encountered  in  which  careful  examination  shows  the  existence  of  a 
body  which  in  size,  shape,  and  position  corresponds  closely  to  a  third  testicle; 
even  the  testicular  sensation — i.e.,  sickening  pain  on  pressure- — may  be  present. 
When  opportunity  has  been  given  for  complete  examination,  these  apparently 
supernumerary  testes  have  been  proved  to  be  encysted  hydroceles,  epiploceles, 
fibromata,  or  other  comparatively  common  pathological  conditions. 

2.  Anorchism. — This  deformity  may  be  unilateral  (monorchism)  or  bi- 
lateral. It  is  usually  unilateral,  and  the  epididymis  and  scrotal,  portion  of  the 
vas  are  also  absent  on  the  affected  side.  The  pelvic  portion  of  the  vas  and 
the  seminal  vesicles  are  ordinarily  present,  though  cases  are  recorded-  showang 
that  even  these  portions  of  the  genital  tract  may  be  wanting.    The  testicle  may 


SURGERY  OF  THE  TESTICLES  301 

be  present,  but  the  epididymis  or  vas  or  both  these  structures  may  be  absent. 
Bilateral  anorchism  is  accompanied  by  absence  or  incomplete  development  of 
the  scrotum,  a  rudimentary  condition  of  external  genitalia,  impotence,  sterility, 
and  the  physical  and  mental  attributes  of  eunuchism. 

3.  Synorchism,  or  fusion  of  the  testicles,  is  an  extremely  rare  condition. 
It  seems  to  have  been  found  only  in  foetal  life.  The  diagnosis  of  the  condition 
is  dependent  upon  the  finding  of  two  cords. 

Diagnosis. — A  distinction  between  bilateral  retention  and  anorchism  may 
be  made  by  the  rudimentary  condition  of  the  penis  when  the  testicles  are  absent, 
and  by  the  later  development  of  eunuchism. 

Treatment. — Unilateral  anorchism  gives  rise  to  no  symptoms,  since  one 
testis,  if  it  remains  healthy,  is  competent  to  perform  the  functions  of  both. 
Bilateral  anorchism  would  seem  to  be  beyond  help  except  by  the  transplantation 
of  testicular  substance.  One  might  thus  so  modify  the  course  of  development 
that,  though  potency  and  fertility  cannot  be  expected,  the  physical  and  mental 
characteristics  of  the  male  may  be  preserved.  While  the  removal  of  either 
testicles  or  ovaries  in  early  life  usually  changes  profoundly  all  the  character- 
istics, physical  and  mental,  of  the  individual,  the  testicles  may  lose  or  may 
never  have  had  the  sperm-producing  power  and  still  possess  the  quality  which 
enables  them  to  hold  the  organism  in  its  normal  groove  and  to  invest  it  with 
the  other  attributes  of  masculinity.  When  testes  fail  to  descend,  as  a  rule 
they  are  incapable  of  producing  spermatozoa.  In  spite  of  this  imperfection 
of  the  organs,  the  external  bodily  characteristics  of  the  male  are  acquired. 

It  is  possible  that  the  function  of  the  testicles  which  relates  to  the  preserva- 
tion of  masculinity,  as  distinguished  from  the  function  of  reproduction,  may 
be  exerted  through  a  definite  substance  which  has  distinct  physiological  proper- 
ties of  its  own,  manifest  to  some  extent  whenever  it  is  introduced  into  the 
system.  It  therefore  seems  reasonable  to  hope  that  regularly  repeated  injections 
of  testiculin  may  exert  a  powerful  influence  on  the  general  development  of  bi- 
lateral anorchids.  These  injections  should  be  instituted  at  an  early  age,  cer- 
tainly before  puberty,  and  should  be  continued  for  many  years.  The  dosage, 
the  number  of  repetitions,  and  the  period  of  time  over  which  treatment  should 
extend  cannot  be  formulated. 

Anomalies   in    Size 

Hypertrophy. — In  common  with  all  the  genital  organs,  the  normal  testicles 
vary  greatly  in  size  and  without  any  definite  relation  to  the  general  physical 
development  or  to  functional  activity.  It  is,  therefore,  difficult  to  determine 
what  degree  of  growth  indicates  a  departure  from  the  normal.  In  cases  where 
one  testicle  has  been  removed  or  has  become  atrophied,  the  remaining  o-land 
may  show  so  marked  an  overgrowth  as  to  be  properly  considered  hypertrophied. 
This  is  particularly  likely  to  occur  when  there  is  congenital  atrophy  or  unilateral 
ectopy.  The  destruction  of  the  testicle  by  inflammation,  unless  this  occurs  in 
early  life,  is  not  commonly  followed  by  enlargement  of  the  other  gland. 

Atrophy.— The  wasting  which  follows  acute  or  chronic  inflammation  cannot 
properly  be  considered  a  congenital  malformation,  even  though  this  atrophic 


302  GENITO-URINARY  SURGERY 

process  takes  place  in  early  infancy.  True  atrophy  is  nearly  always  observed 
in  cases  of  non-descent  and  ectopy.  Even  when  the  position  of  the  organ  is 
perfect  one  or  both  testes  may  remain  puerile.  It  is  a  matter  of  clinical 
observation  that  these  puerile  testes  may  attain  full  development  as  a  result  of 
physiological  activity. 

Treatment. — Hypertrophy  calls  for  no  treatment,  since  it  is  compensatory 
and  is  dependent  upon  increased  physiological  activity.  It  is  probable  that  a 
gland  thus  enlarged  is  more  vulnerable  than  one  of  normal  size:  hence  it  is 
desirable  to  support  it  by  a  suspensory  bandage  if  the  scrotum  is  relaxed,  and 
to  caution  the  patient  as  to  the  special  danger  incident  to  urethritis. 

The  treatment  of  imperfect  development  of  the  testes  promises  little.  There 
is,  however,  sufficient  clinical  evidence  to  prove  that  persistent,  long-continued 
treatment  may  be  followed  by  gratifying  results.  Thyroid  extract,  pituitrin, 
and  desiccated  pineal  gland  would  all  seem  indicated.  The  stimulating  influ- 
ence of  massage  regularly  administered  should  be  borne  in  mind,  and  the  effect 
which  physiological  activity  has  upon  growth  and  nutrition  should  be  considered 
in  advising  such  patients  and  in  predicting  as  to  their  future. 

The  bringing  down  of  an  undescended  testicle  has  been  followed  by  rapid 

increase  in  size. 

ANOMALIES  IN  MIGRATION 

The  testicle  may  be  arrested  in  its  transit  from  below  the  kidney  to  the 
bottom  of  the  scrotum  at  any  portion  of  its  course.  It  may  depart  from  its 
regular  path,  taking  an  aberrant  course,  or,  having  descended  normally,  it  may 
assume  a  faulty  position  in  the  scrotum. 

Arrest  of  Passage  in  the  Normal  Course 
The  testicle  may  be  arrested  in  the  abdominal  cavity  or  in  the  inguinal  canal, 
or  may  incompletely  descend  into  the  scrotum — the  condition  known  as  cryp- 
torchidism. 

Abdominal  retention  may  be  unilateral  or  bilateral.  The  testicle  may 
be  found  close  to  the  posterior  abdominal  wall  in  relation  to  the  lower  border 
of  the  kidney,  it  may  be  provided  with  a  long  mesorchium  allowing  it  to  move 
freely  in  the  abdominal  cavity,  or  it  may  lie  in  the  iliac  fossa  close  to  the 
internal  ring. 

In  inguinal  retention  the  testicle  may  be  arrested  at  the  internal  ring,  in 
the  inguinal  canal,  or  at  the  external  ring  (Fig.  156),  and  until  it  becomes 
adherent  by  inflammation  it  is  usually  extremely  mobile.  This  variety  is  most 
important  because  of  its  frequency,  because  from  its  exposed  position  the 
testicle  is  subject  to  irritation  and  injury,  and,  finally,  because  it  is  liable  to 
be  mistaken  for  hernia  and  usually  has  this  as  an  associated  condition. 

In  incomplete  scrotal  descent  (cruro-scrotal  retention)  the  testicle  lies  outside 
of  the  inguinal  canal,  but  fails  to  descend  completely,  and  is  found  in  the  fold 
between  the  scrotum  and  the  thigh,  at  varying  distances  from  the  ring. 

When  the  testicle  takes  an  aberrant  course  (ectopy)  it  may  be  found 
beneath  the  skin  of  the  abdominal  wall  at  a  variable  distance  from  the  external 
abdominal  ring,  in  the  crural  region,  or  in  the  perineum. 

In  perineal  ectopy  the  testicle  is  found  as  a  distinct  ovoid  tumor,  lying  to 


SURGERY  OF  THE  TESTICLES 


303 


one  side  of  the  central  raphe  and  in  front  of  the  anus.  The  cord  can  often 
be  traced  from  this  tumor  to  the  external  abdominal  ring,  and  the  overlying 
skin  sometimes  presents  the  peculiarities  of  the  scrotum,  the  corresponding  side 
of  this  sac  being  generally  atrophied.  A  testis  thus  placed  can  scarcely  escape 
frequent  injury,  with  consequent  inflammation  and  destruction  of  secreting 
structure. 

In  femoral  ectopy  the  testicle  occupies  the  position  of  a  complete  femoral 
hernia,  though  Curling  notes  a  case  in  which  the  gland  was  three  inches  below 
Poupart's  ligament  and  behind  the  femoral  vein,  with  the  cord  encircling  this 
vessel.  The  testicle  passes  beneath  Poupart's  ligament  and  through  the  saphen- 
ous opening. 

Curling,  after  considering  the  etiology  of  nondescent,  maintains  that  in  some 


Fig.  156. — Undescended  testis:  Xote  the  inguinal  swelling  with 
corresponding  atrophy  of  the  scrotum.  (Case  of  unilateral  inguinal  cryptor- 
chism  and  phimosis.) 

cases  retention  is  due  to  the  small  size  of  the  external  ring.  Other  causes  which 
may  be  operative  are  the  application  of  a  tight-fitting  truss  before  the  descent 
of  the  testis,  shortness  of  the  vessels  of  the  cord,  and  a  long  mesorchium  pre- 
venting the  testicle  from  entering  the  canal. 

The  irregular  development  of  the  gubernaculum  will  explain  crurofemoral 
and  peno-pubic  ectopy.  The  lower  attachments  of  this  fibro-muscular  structure 
are  Poupart's  ligament  in  the  course  of  the  inguinal  canal  (Curling),  the  lower 
part  of  the  scrotum,  and  the  pubic  bone.  There  are  also  fibres  passing  to 
the  region  of  the  saphenous  opening.  Relative  over-development  of  certain 
of  these  bands  may  draw  the  testicle  into  a  faulty  position. 

As  a  rule,  misplaced  testicles  are  undersized,  though  apparently  healthy 
until  they  have  been  subjected  to  repeated  attacks  of  inflammation.     When 


304  GENITO-URINARY  SURGERY 

removed  from  the  adult  and  examined  they  show  degeneration  and  atrophy  of 
the  secreting  structure.  This,  however,  is  inflammatory  in  nature  and  not 
inseparably  connected  with  under-development.  Curling  holds  that  undescended 
testicles  are  functionless  so  far  as  reproduction  is  concerned,  and  hence  that 
bilateral  retention  causes  sterility,  though  not  necessarily  impotence. 

Monod  and  Arthaud  have  attempted  to  demonstrate,  on  the  other  hand, 
that  a  retained  testicle  may  secrete  healthy  semen  and  show  no  degenerative 
changes  on  section,  such  alterations  being  due  to  repeated  inflammations  to 
which  the  gland  is  necessarily  subject  from  its  faulty  position.  In  one  unde- 
scended testicle  which  we  removed  from  a  man  forty-five  years  old  in  the 
course  of  a  radical  operation  for  strangulated  hernia,  microscopic  section  of 
the  gland,  which  was  about  the  size  of  that  normally  found  in  a  child  of 
twelve,  showed  it  to  be  fully  functional,  although  it  had  been  subject  to  a 
number  of  inflammatory  attacks. 

Incomplete  transit  is  most  commonly  manifested  in  the  form  of  inguinal 
retention;  the  aberrant  transit,  in  the  form  of  perineal  ectopy. 

CoiviPLiCATiONS  OF  MISPLACED  TESTICLES. — Hernia,  inflammation,  and  ma- 
lignant degeneration  are  the  serious  complications  of  abnormally  placed  testes. 

Hernia  is  an  extremely  common  complication,  and  is  of  the  congenital 
variety — i.e.,  there  is  a  direct  communication  from  the  abdominal  cavity  to 
the  testis,  the  funicular  portion  of  the  peritoneal  sac  not  having  become  obliter- 
ated. The  funicular  form  is  also  found;  in  this  the  testicle  is  shut  off,  but 
the  peritoneal  pouch  which  descends  with  the  cord  still  remains  patulous. 
Hernia  is  a  grave  complication  of  misplaced  testis,  since  it  is  especially  liable 
to  sudden  and  complete  strangulation.  Because  of  the  presence  of  the  testicle 
a  retaining  truss  can  rarely  be  worn. 

Inflammation  frequently  attacks  a  misplaced  testicle,  particularly  the 
inguinal  form,  since  the  imperfectly  developed  gland  seems  to  be  especially 
vulnerable.  Inflammation  may  be  due  to  traumatism  or  to  extension  of  infection 
from  the  posterior  urethra.  Traumatic  inflammation  may  be  caused  by  a  blow 
or  by  sudden  contraction  of  the  abdominal  muscles,  which  pinch  the  testicle 
in  its  already  too  straitened  environment.  It  is  probable  that  the  misplaced 
testicle  is  not  immune  against  the  infection  which  develops  in  the  course  of 
mumps,  typhoid  fever,  and  other  diseases  which  are  often  complicated  by 
orchitis.  Jacobson  states  that  syphilis  and  tuberculosis  have  not  been  observed 
to  attack  such  testes. 

Malignant  Degeneration. — The  comparative  frequency  with  which  malig- 
nant disease  attacks  misplaced  testicles  is  generally  recognized.  The  predis- 
position is  probably  due  to  the  frequent  inflammatory  attacks  to  which  the 
gland  is  subjected. 

Symptoms. — Symptoms  of  anomalies  of  migration  of  the  testis  are  wanting. 
Until  the  onset  of  complications  there  will  be  no  complaint,  except  perhaps 
slight  transitor}'-  testicular  pain,  caused  by  sudden  violent  muscular  exertion  or 
by  blows  or  jars  in  the  region  of  the  misplaced  gland.  The  complications  are, 
however,  extremely  important,  since  some  of  them  directly  threaten  life. 


SURGERY  OF  THE  TESTICLES  305 

The  symptoms  of  orchitis  are  practically  the  same  whether  the  testis  is 
descended  or  undescended. 

Hydrocele  and  haematocele  frequently  complicate  inflammation.  Hydrocele 
may  be  of  the  congenital  variety, — that  is,  reducible  into  the  peritoneal  cavity; 
sooner  or  later  it  becomes  distinctly  limited. 

Exceptionally,  the  testicular  inflammation  may  cause  general  peritonitis; 
Curling  has  reported  one  death  from  this  complication.  Very  commonly 
abdominal  symptoms  develop  so  suddenly  and  violently  that  they  closely  simu- 
late those  dependent  upon  the  presence  of  a  strangulated  hernia.  There  may 
be  tympany,  tenderness,  constipation,  and  vomiting  so  persistent  as  to  have  a 
markedly  stercoraceous  character.  The  distinction  between  orchi-epididymitis 
attacking  an  undescended  testicle  and  strangulated  inguinal  hernia  is  often  ex- 
tremely difficult  to  make. 

Hernia  when  it  complicates  undescended  testicle  is  manifested  by  the  usual 
symptoms,  but  will  often  exhibit  the  peculiarity  of  not  being  amenable  to 
treatment  by  truss,  pressure  of  the  pad  producing  so  much  pain  that  it  cannot 
be  borne.  The  hernia  may  pass  beyond  the  testis,  reaching  the  scrotum;  some- 
times it  pushes  the  testis  in  front  of  it,  thus  curing  the  displacement.  When 
the  hernia  becomes  strangulated  the  symptoms  are  not  different  from  those 
commonly  observed  in  strangulated  hernia. 

Malignant  degeneration  exhibits  the  symptoms  which  characterize  cancer  of 
the  normally  placed  testis,  except  the  location  of  the  tumor.  The  testicle  steadily 
and  rapidly  enlarges,  becomes  irregular  in  shape,  often  cystic,  painful,  and 
involves  the  anatomically  related  glands.  The  skin  is  discolored  and  marked 
by  large  veins.  In  cases  of  abdominal  retention  the  diagnosis  cannot,  of  course, 
be  formulated  until  the  tumor  has  reached  considerable  size,  since  till  then  it 
is  not  palpable.  A  persistent,  steadily  increasing,  obstinate  pain  should  in 
the  case  of  abdominal  retention  suggest  the  possibility  of  malignant  infiltration. 
In  the  late  course  of  malignant  disease  the  diagnosis  is  made  clear  by  the  large 
palpable  tumor  and  glandular  involvement. 

Diagnosis. — The  diagnosis  of  misplaced  testicle  is  based  on  (1)  the  absence 
of  the  gland  from  its  normal  position;  in  infants  and  young  children  the  testes 
may  be  extremely  small,  sometimes  not  much  larger  than  a  kidney-bean,  and 
because  of  their  great  mobility  may  be  hard  to  find;  (2)  the  detection  in  the 
abnormal  position  of  a  smooth,  usually  movable  tumor,  shaped  like  a  normal 
testicle,  but  smaller,  and  yielding  on  pressure  the  testicular  sensation ;  in  making 
this  examination,  unless  the  testis  is  found,  the  patient  should  be  instructed 
to  cough  and  strain,  since  thus  there  may  be  brought  within  reach  an  unde- 
scended testis  lying  high  up  in  the  inguinal  canal;  (3)  atrophy  of  the  scrotum 
of  the  side  corresponding  to  the  misplacement  (Fig.  192).  In  cases  of  ab- 
dominal retention  the  only  signs  are  absence  of  the  testis  from  the  normal 
position  and  atrophy  of  the  scrotum. 

Prognosis. — The  prognosis  of  imperfect  descent  of  testicles  is  fairly  good 
in  young  children,  since  ultimately  the  gland  is  likely  to  reach  its  proper  position. 
This  is  not  true  of  ectopy.  In  case  the  gland  does  not  descend  before  birth, 
it  commonly  does  so  shortly  afterwards,  and  no  anxiety  should  be  experienced 
for  several  weeks,  especially  if  the  testicles  can  be  felt  in  the  inguinal  region 
20 


306 


GEXITO-URIXARY  SURGERY 


and  the  scrotum  is  properly  developed.  If  the  descent  does  not  take  place 
during  infancy  or  childhood,  there  is  still  a  chance  that  it  may  occur  about 
the  period  of  puberty,  sometimes  as  the  result  of  violent  straining  effort.  The 
gradual  descent  is  often  complicated  b}^  hernia. 

As  a  rule,  a  testicle  which  has  shown  no  signs  of  descent  by  the  sixth  year 
will  retain  its  faulty  position  unless  subjected  to  surgical  treatment. 

Treatment. — Abdominal  cr^-ptorchidism  is  difficult  to  remedy — at  times 
impossible — as   the   vascular    and   nervous    attachments    are   very    short,    and 


Fig.  157. — Second  step  in  operation  for  undescended  testicle.  The 
vagina!  tunic  has  been  cut  across  above  the  testicle,  and  the  upper  extremity 
ligated.  Tlie  distal  end  is  being  closed  in  order  to  form  a  closed  tunica  vagi- 
nalis for  the  testicle. 

in  some  cases  the  gland  cannot  be  located;  nor  in  the  absence  of  symptoms 
(strangulation,  inflammation,  neoplasm)  should  a  proper  placement  be  at- 
tempted. Guelliot.  however,  reports  a  most  suggestive  case.  He  operated  for 
bilateral  abdominal  nondescent:  one  testis  was  secured  in  the  scrotum;  two 
years  later  this  gland  was  well  developed,  and  the  boy,  then  eighteen  years  old, 
was  normal  in  regard  to  his  sexual  functions.  In  the  semen  were  found  a  few 
apparently  normal  spermatozoa.  While  it  is  probable  that  patients  subject  to 
bilateral  abdominal  retention  of  the  testicle  will  be  sterile,  they  are  likely  to 


SURGERY  OF  THE  TESTICLES 


307 


suffer  from  no  inconvenience,  since  the  gland  is  so  placed  as  to  be  protected 
from  injury. 

Inguinal  retention  should  be  treated  conservatively  in  early  life,  the  gland 
being  encouraged  to  descend  to  its  normal  position  by  gentle  manipulation  with 
the  fingers.  Persistence  in  this  treatment  is  justifiable  to  the  sixth  or  eighth 
year  if  the  testicle  in  the  meantime  does  not  become  inflamed  or  show  signs 
of  atrophy.  After  the  sixth  year  the  operative  treatment  may  be  considered, 
but  it  should  be  remembered  that  spontaneous  descent  may  take  place  about 
the  period  of  puberty;  this  is,  however,  not  the  rule.  Operation  is  especially 
indicated  if  the  malformation  is  bilateral,  if  the  testicle  has  been  subject  to  re- 
peated attacks  of  inflammation,  if  a  complicating  hernia  be  present,  or  if  from 


Fig.  158. — Showing  floor  of  inguinal  canal  split  from  the 
internal  inguinal  ring  to  the  pubis,  dividing  the  deep  epigastric 
vessels  and  exposing  the  vas  deferens  and  in  silhouette  the  sper- 
matic vessels  lying  on  the  peritoneum  before  they  join  to  form 
the  spermatic  cord.  (From  Surgery,  Gynaecology,  and  Obstet- 
rics,  March,    1911.) 

its  position  and  its  chronically  inflamed  condition  it  prevents  proper  indulgence 
in  active  sports. 

Since  one  of  the  reasons  for  operating  is  to  encourage  growth,  it  should  be 
undertaken  before  the  most  active  period  of  development. 

Operative  Treatment. — An  incision  is  made  appropriate  for  inguinal  her- 
nia, and  the  testicle  and  cord  are  freed  from  adhesions.  In  practically  all  cases 
the  tunica  vaginalis  is  found  to  communicate  with  the  abdominal  cavity.  This 
condition  is  treated  by  dividing  the  funicular  process  immediately  above  the 
testicle,  ligating  or  suturing  the  distal  portion  so  as  to  close  the  tunica  vaginalis, 
and  ligating  the  proximal  portion  at  the  internal  ring  (Fig.  157).  The  testicle 
is  then  drawn  toward  the  scrotum  so  that  the  structures  of  the  cord  are  put 


308 


GENITO-URINARY  SURGERY 


on  the  stretch,  and  any  adventitious  bands  and  all  cremasteric  fibres  are  divided. 
At  times  this  enables  the  operator  to  place  the  testicle  in  the  bottom  of  the 
scrotum  without  tension.  Usually  further  freeing  is  needful;  this  may  be  accom- 
plished by  either  of  two  methods,  those  of  Bevan  and  Davison. 

Bevan's  Method. — The  structures  of  the  cord  are  divided  into  two  portions — 
the  vas  deferens  and  its  vessels  and  nerves,  in  close  contact  with  it  and  the 
pampiniform  plexus;  the  latter  may  be  sacrificed  if  needful.  When,  therefore, 
it  is  found  necessary  to  lengthen  the  cord  Bevan  advises  section  of  the  spermatic 
vessels  between  ligatures. 

Davison's  Method. — Here  advantage  is  taken  of  the  fact  that  not  only  is 
there  an  angle  in  the  course  of  the  vas  and  its  vessels,  the  turning  inward  at 
the  internal  ring,  but  also  in  the  course  of  the  spermatic  vessels  (Fig.  158). 
The  bending  here  is  outward,  and  lies  just  to  the  outer  side  of  the  internal  ring. 


Fig.  159. — Diagram  of  the  transplantation  of  vas  deferens 
and  spermatic  vessels — lowering  the  cord,  the  difference  be- 
tween b.  a.  and  b.  c.  a.  (From  Surgery,  Gynaecology,  and 
Obstetrics,    March,    1911.) 

The  operation  consists  in  moving  the  internal  ring  mesially  till  it  lies  behind 
the  external  ring  (Fig.  159),  and  is  accomplished  by  ligating  the  deep  epigastric 
artery  between  ligatures,  incising  the  posterior  wall  of  the  inguinal  canal,  formed 
by  the  transversalis  fascia,  so  that  the  peritoneum  is  exposed,  and  then  by  blunt 
or  gauze  dissection  freeing  first  the  vas  and  its  vessels  and  then  the  spermatic 
vessels,  the  cut  edge  of  the  transversalis  fascia  being  drawn  downward  and 
outward  to  facilitate  the  latter  procedure. 

When  a  sufficient  length  of  cord  has  been  obtained,  a  bed  for  the  testicle  is 
made  in  the  scrotum  by  blunt  dissection  with  the  fingers,  and  the  testicle  is 
placed  and  retained  therein.  This  retention  is  not  always  an  easy  matter. 
Sometimes  it  may  be  accomplished  by  suturing  the  tissues  about  the  cord  at 
the  upper  part  of  the  scrotum,  by  suturing  the  cord  to  the  external  ring,  or  by 


SURGERY  OF  THE  TESTICLES  309 

suturing  the  testicle  to  the  bottom  of  the  scrotum,  the  suture  being  passed 
through  the  gubernaculum  testis  or  the  tunica  propria  of  the  testis  and  through 
scrotal  skin,  the  knot  being  tied  on  the  outside.  Debule  has  suggested  passing 
the  testicle  through  an  incision  in  the  scrotum  and  suturing  it  temporarily  to 
the  deep  fascia  of  the  thigh,  the  skin  of  scrotum  and  thigh  being  also  united 
by  suture.  Davison  advocates  bringing  the  ends  of  a  suture  of  silkworm  gut 
which  has  been  passed  through  the  gubernaculum  testis  through  the  bottom  of 
.the  scrotum,  and  attaching  them  to  a  light  rubber  band,  the  other  end  of  which 
is  attached  to  a  piece  of  adhesive  plaster  fastened  about  the  thigh  above  the 
knee;  in  his  case  the  thigh  must  be  kept  in  extension  by  a  plaster-of-Paris  or 
other  fixative  dressing.  In  all  cases  careful  suture  should  close  the  inguinal  canal 
and  reduce  the  opening  through  which  the  cord  passes  to  its  safe  minimum. 

Ectopy   of   the    Testicle 

Perineal  ectopy  should  always  be  subjected  to  operation,  since  from'  its 
position  the  testicle  is  exposed  to  frequent  injury.  It  is  well  to  wait  until  the 
third  or  fourth  year  of  Hfe  before  attempting  replacement,  because  after  that 
time  there  is  less  danger  of  infection  through  soiling  the  dressings.  This  plan 
is  advisable,  provided  the  testis  is  not  injured  by  the  exercises  of  early  child- 
hood, such  as  walking,  running,  and  playing.  The  wound  can,  however,  be' 
almost  perfectly  protected  by  the  application  of  a  collodion  dressing. 

The  testicle  is  pushed  as  hear  the  scrotum  as  possible,  and  an  inch  and  a 
half  incision  is  made  on  the  scrotal  side  of  the  testis  and  at  right  angles  to 
the  raphe,  exposing  the  cord;  by  drawing  upon  this  structure  and  by  the  use 
of  retractors  the  testicle  can  be  exposed  and  the  fibrous  adhesions  binding  it 
to  its  faulty  position  divided.  Through  the  cellular  tissue  a  way  is  then  made 
to  the  bottom  of  the  scrotum;  this  pouch  is  invaginated  into  the  wound,  the 
base  of  the  testis  and  the  epididymis  are  secured  to  it  by  two  or  three  sutures, 
and  the  perineal  wound  is  sutured  at  right  angles  to  its  length,  thus  deepening 
the  scrotal  pouch. 

Pubic  and  crural  ectopy  are  so  rarely  found  that  their  treatment  by  opera- 
tive procedures  has  not  been  formulated.  A  testicle  placed  in  front  of  the  pubis 
at  the  root  of  the  penis  may  be  transplanted  into  the  scrotum  without  difficulty. 

In  crural  ectopy  the  testis  should  be  reduced  into  the  abdominal  cavity,  to- 
gether with  the  hernia  which  usually  accompanies  it,  and  should  be  retained 
by  suture.  Failing  this,  a  protecting  truss  may  be  applied.  If  the  testis  is 
still  subject  to  attacks  of  inflammation,  castration  is  generally  advised,  though 
from  the  surgical  point  of  view  there  seems  no  good  reason  why  the  testis  could 
not  be  placed  in  its  proper  position  by  freeing  it  and  its  cord  and  dividing 
Poupart's  ligament. 

Treatment  of  Complications  of  Misplaced  Testicle.— Inflammation. — 
The  general  indications  in  the  treatment  of  inflammation  of  an  undescended  or 
ectopic  testis  are  those  appropriate  to  a  like  condition  of  the  normally  placed 
gland.  Rest  in  bed,  elevation  of  the  pelvis,  moderate  purgation,  the  application 
of  heat  or  cold,  depending  upon  the  preference  of  the  patient,  and  the  relief  of 
pain  by  hypodermic  injections,  represent  the  general  line  of  treatment.  When 
the  inflammation  ranges  high  and  there  is  doubt  in  regard  to  diagnosis,  there 


310  GENITO-URINARY  SURGERY 

should  be  no  hesitation  in  making  an  incision  and  exposing  the  gland,  since 
the  relief  of  tension  thus  secured  is  immediately  followed  by  marked  alleviation 
of  pain. 

Hernia. — When  cryptorchidism  is  complicated  by  hernia,  and  the  latter 
exhibits  a  tendency  to  push  the  misplaced  testis  before  it,  thus  favoring  its 
descent,  no  retention  apparatus  should  be  applied  until  the  gland  has  escaped 
from  the  external  ring.  A  truss  should  then  be  so  adjusted  that  it  will  keep  the 
hernia  from  descending  and  push  the  testis  still  farther  down.  Cases  are  rare 
in  which  the  hernia  exhibits  this  tendency.  More  frequently  it  slips  beyond 
the  testicle,  escaping ' through  the  external  abdominal  ring  before  the  gland;  a 
truss  is  then  insupportable,  and  operation  offers  the  only  prospect  of  cure. 
If  the  patient  is  young  and  the  testicle  has  not  been  repeatedly  inflamed,  the 
gland  is  brought  to  its  normal  position  in  the  scrotum  and  the  hernia  is  radically 
cured.  If  there  have  been  repeated  attacks  of  inflammation  it  is  usually  de- 
sirable to  remove  the  testicle,  entirely  closing  the  rings  and  canal. 

Malignant  grov^th  should  be  treated  by  early  and  complete  removal. 
When  the  testicle  is  intra-abdominal  this  form  of  intervention  is  rarely  practicable 
until  the  disease  has  become  so  well  developed  that  there  is  no  prospect  of 
radical  cure,  since  diagnosis  cannot  be  made  until  a  decided  tumor  develops. 
In  inguinal  ectopy  enlargement  of  the  gland  may  be  detected  early.  Therefore 
operative  interference  promises  better  results.  Whenever  an  undescended  testicle 
increases  in  size  without  inflammatory  phenomena,  operation  should  be  per- 
formed immediately.  The  removal  of  malignant  testicle  is  usually  unattended 
with  operative  difficulty. 

Torsion. — The  undescended  testicle  seems  to  be  particularly  subject  to  the 
accident  of  strangulation  by  torsion.  When  symptoms  of  extremely  severe 
inflammation  develop  with  unusual  suddenness  and  severity  and  without  obvi- 
ously sufficient  cause,  incision  and  exposure  of  the  undescended  testis  are  indi- 
cated. The  cord  may  be  untwisted  or  the  testis  removed.  The  latter  course  is 
desirable,  when  but  one  organ  is  affected,  since  testes  subject  to  torsion  are 
liable  to  undergo  malignant  degeneration. 

Inversion  of  the  Testicle 

The  testicle,  though  it  descend  to  the  bottom  of  the  scrotum,  may  assume 
various  faulty  positions  termed  inversions.  This  displacement  may  be  anterior, 
horizontal,  or  lateral.  The  anterior  form  is  commonest,  the  testicle  being  rotated 
completely,  the  epididymis  lying  in  front,  the  free  border  to  the  rear. 

No  treatment  is  indicated  in  these  cases,  displacement  being  important 
mainly  when  surgical  intervention  is  required, — for  the  cure  of  hydrocele,  for 
instance.  With  this  present  in  the  case  of  anterior  inversion,  the  testicle  and 
epididymis  would  lie  in  front  and  not  behind  the  fluid  contained  in  the  sac 
of  the  vaginal  tunic;  hence  were  a  trocar  introduced  at  the  customary  point 
it  would  wound  both  the  testicle  and  epididymis.  The  possibility  of  inversion 
is  a  reason  for  invariably  examining  hydrocele  by  transmitted  light  before 
tapping.  When  the  sac-wall  is  thick  or  the  contents  are  turbid  careful  palpation 
will  usually  elicit  the  testicular  sensation,  suggesting  the  faulty  position  of 


SURGERY  OF  THE  TESTICLES  311 

the  gland.  Monod  and  Terrillon  advise  that  in  tapping  cases  where  the  posi- 
tion of  the  testicle  remains  in  doubt,  the  puncture  should  be  made  on  the 
outer  side  of  the  scrotum  instead  of  in  front. 

Of  the  other  forms  of  inversion  fewer  cases  have  been  reported,  nor  are 
they  of  great  surgical  importance.  In  the  horizontal  variety  the  long  axis  of 
the  gland  lies  in  the  horizontal  position,  the  epididymis  looking  upward.  Lateral 
inversion  is  a  modification  of  the  anterior  variety.  Reversion  of  the  testis  has 
been  reported  by  a  few  observers;  the  upper  end  of  the  gland  looks  downward. 
We  have  seen  one  such  case. 

Luxation   of   the   Testicle 

The  testicles  may  be  displaced  by  direct  traumatism  or  muscular  action. 
The  ordinary  cause  of  this  displacement  is  sudden  violent  contraction  of  the 
cremaster  muscle  reflexly  excited  in  the  course  of  a  severe  general  muscular 
strain.  The  testis  may  be  fixed  in  the  groin  external  to  the  ring  from  tonic 
spasm  of  the  cremaster,  may  be  lodged  in  the  inguinal  canal,  or  may  be  drawn 
even  within  the  abdominal  cavity;  it  is  generally  found  within  the  inguinal 
canal.  It  shortly  becomes  inflamed  and  is  subject  to  the  general  accidents 
already  considered  under  the  head  of  congenital  displacement. 

Treatment. — The  treatment  of  luxated  testicle  is  prompt  replacement. 
This  usually  requires  the  administration  of  ether,  since  inflammation  develops 
rapidly  and  the  gland  becomes  excessively  tender.  If  the  testicle  is  held  in  its 
faulty  position  by  adhesions  or  tonic  contraction  of  the  cremaster  muscle,  the 
operation  for  incomplete  descent  is  indicated. 

Torsion  of  the  Testicle 

Torsion  or  axial  rotation  of  the  spermatic  cord  sufficiently  describes  the 
nature  of  this  accident.  It  is  one  of  sudden  development,  usually  affecting  the 
cords  of  undescended  testes,  though  by  no  means  confined  to  these.  The  cause 
of  this  twist  has  not  been  formulated;  it  is  probably  dependent  upon  congenital 
malformation,  since  Owen  has  pointed  out  that  a  testis  properly  placed  in  the 
scrotum  and  possessed  of  a  normal  mesorchium  cannot  be  twisted.  The  twist 
may  be  either  to  the  right  or  to  the  left,  and  in  accordance  with  its  extent  and 
the  degree  of  constriction  to  which  the  vessels  are  subject  the  symptoms  are 
slight  or  severe.  In  slight  cases  the  epididymis  alone  becomes  infiltrated. 
In  severe  cases  the  entire  gland  with  the  epididymis  becomes  gangrenous, 
exhibiting  extensive  blood  extravasations. 

Symptoms. — The  symptoms  of  torsion  are  those  of  epididymitis  or  orchi- 
epididymitis. They  occur  suddenly,  often  without  apparent  cause,  during  active 
muscular  exertion.  WTien  the  rotation  is  sufficient  to  produce  complete  strangu- 
lation the  symptoms  are  violent  and  rapidly  progressive.  In  cases  of  abdominal 
or  inguinal  retention  these  symptoms  may  be  augmented  by  those  of  a  local 
peritonitis.     The  lesion  has  occurred  in  infants. 

Diagnosis. — A  positive  diagnosis  is  rarely  possible  without  direct  ex- 
ploration through  an  incision,  the  symptoms  suggesting  an  excessively  acute 
orchi-epididymitis  or  a  strangulated  hernia.  Since  torsion  commonly  affects  an 
undescended  testis — so  often  complicated  by  hernia — the  differential  diagnosis 
may  be  extremely  difficult.    The  inguinal  tumor  is  painful,  swollen,  sometimes 


312  GEXITO-URIXARY  SURGERY 

reddened  and  oedema tous,  and  gives  no  impulse  on  coughing;  it  develops  quite 
suddenly  after  exertion.  Vomiting  and  tympany  are  by  no  means  uncommon. 
These  symptoms  are  so  like  those  of  strangulation — indeed,  are  so  indistinguish- 
able from  this  condition — that  immediate  exploratory  operation  is  indicated. 

When  the  testis  occupies  a  normal  position  there  is  little  likelihood  of  con- 
founding a  t\vist  of  the  cord  with  hernia  unless  the  latter  has  been  a  previous 
compHcation,  since  the  cord  can  be  felt  above  the  swelling  and  the  inguinal 
canal  is  free  from  hernial  sac  or  contents. 

The  diagnosis  of  torsion  will,  then,  depend  mainly  upon  the  suddenness  of 
onset,  the  severity  of  symptoms,  and  the  absence  of  other  sufficient  causes  for 
acute  inflammation.  Moreover,  the  epididymis  may  be  felt  in  front  of  the 
testis,  and  a  nodulation  corresponding  to  the  twist  may  be  distinguishable. 

Prognosis. — If  untreated,  the  testicle  will  either  atrophy  or  become  gan- 
grenous; gangrene  probably  depends  upon  hsematogenous  infection  of  the  de- 
vitaUzed  area. 

Treatment. — Reduction  should  be  effected  by  manipulation  or  by  opera- 
tion. Rotation  must  be  made  in  the  direction  opposite  to  that  which  is  causa- 
tive of  pain. 

When  the  patient  is  not  seen  earty,  and  when  the  inflammatory  phenomena 
are  pronounced,  incision  is  indicated.  This  should  expose  the  testicle  and  cord. 
If  the  gland  is  black  and  gangrenous  it  should  be  removed.  Otherwise  the  cord 
should  be  untwisted,  one  lateral  surface  of  the  testicle  secured  to  the  scroturh 
by  several  sutures,  including  the  proper  tunic  of  the  gland  and  the  deeper 
layers  of  the  skin,  and  the  wound  closed.  When  the  testicle  is  greatly  swollen 
and  discolored,,  even  though  it  is  not  absolutely  certain  that  gangrene  has  taken 
place,  it  is  advisable  to  remove  it  if  the  testis  on  the  other  side  is  healthy. 

CONTUSIONS  AND  WOUNDS  OF  THE  TESTICLE 
Contusion. — The  testicles  from  their  position  and  mobility  usually  escape 
the  effects  of  sudden  direct  pressure  applied  to  the  region  of  the  perineum  and 
scrotum.  They  may,  however,  be  pinched  against  the  pubis  or  perineum  or  be 
bruised  by  a  blow  or  a  squeeze.  The  lightest  form  of  contusion — such  as  that 
sometimes  experienced  in  crossing  the  legs  or  riding  the  bicycle — is  attended 
by  momentary  sickening  pain,  with  a  slight  sense  of  soreness,  which  may  last 
a  few  minutes  or  even  a  day  or  two,  and  probably  is  not  attended  by  distinct 
lesion,  except  in  those  who  previously  have  been  subject  to  latent  disease,  such 
as  tuberculosis  or  tumor. 

Monod  and  Terrillon,  on  the  basis  of  an  experimental  investigation,  classify 
testicular  contusions  as  of  three  degrees:  the  first  is  characterized  by  minute 
disseminated  capillary  hemorrhages  into  the  connective  tissue  lying  between 
the  seminal  tubules  and  the  convolutions  of  the  epididymis.  There  is  often 
epithelial  exfoliation  from  the  inner  surface  of  the  epididymis.  Larger  blood 
effusions  characterize  the  second  degree,  and  there  is  laceration  of  the  tubules; 
the  extravasations  may  vary  from  the  size  of  a  pea  to  that  of  a  cherry.  The 
third  degree  of  contusion  is  characterized  by  rupture  of  the  tunica  albuginea. 
The  gland  is  practically  crushed,  and  there  is  bleeding  into  the  vaginal  tunic, 
with  the  formation  of  acute  hsematocele. 


SURGERY  OF  THE  TESTICLES  315 

Symptoms. — These  vary  in  accordance  with  the  extent  of  injury.  Slight 
contusions  are  characterized  by  a  feehng  of  faintness,  intense  sickening  pain, 
retraction  of  the  testicle,  and  rather  rapid  swelling.  When  the  contusion  is 
severe  there  may  be  profound  shock  or  almost  instant  death. 

The  first  exhausting,  almost  unbearable  anguish  is  of  comparatively  brief 
duration.  There  follows  a  severe,  unremitting  ache,  aggravated  by  standing, 
coughing,  or  straining.  This  persists  until  reactionary  phenomena  have  reached 
their  height,  and  is  so  harassing  that  anodynes  are  required  for  its  relief.  The 
swelling,  which  becomes  perceptible  within  a  very-  few  minutes  and  develops 
rapidly,  is  due  in  part  to  effusion  of  blood  and  serum  into  the  vaginal  tunic,  in 
part  to  oedema  of  the  loose  cellular  tissue  of  the  scrotum.  Profound  discolora- 
tion is  common,  and  is  caused  by  rupture  of  the  vessels  of  the  scrotum; 
exceptionally  it  is  due  to  bleeding  from  the  testis  and  epididymis  or  cord.  The 
inflammation  usually  remains  aseptic,  reaches  its  height  in  from  five  to  eight 
days,  and  subsides  slowly.  Exceptionally  suppuration  occurs.  In  this  case,  in 
place  of  subsiding,  the  symptoms  increase  in  severity,  the  patient  suffers  from 
chill  and  fever,  redness  and  oedema  become  especially  well  marked,  and  finally 
fluctuation  is  detected. 

Prognosis. — In  slight  contusions,  characterized  by  transitory  pain  and  dis- 
ability, lasting  at  most  a  few  hours,  the  prognosis  is  favorable.  In  the  severer 
form  of  contusion  {i.e.,  those  putting  a  patient  to  bed  for  one  or  two  weeks) 
an  opinion  as  to  the  future  integrity  of  the  testicle  should  not  be  expressed  too 
confidently.  In  a  certain  number  of  such  cases  atrophy  develops,  apparently 
uninfluenced  by  treatment.  Atrophy  may  follow  even  slight  bruises,  and  is 
most  apt  to  occur  during  youth;  the  epididymis  is  usually  spared.  In  the 
severest  forms  of  contusion,  characterized  by  rupture  of  the  albuginea,  atrophy 
is  certain  to  result. 

The  atrophic  processes  may  be  progressive  and  uninterrupted,  the  testicle 
regaining  its  normal  size  on  disappearance  of  the  inflammatory  swelling,  and 
then  continuing  slowly  to  shrink,  or  the  acute  inflammation  may  be  succeeded 
by  a  condition  of  chronic  irritation,  characterized  by  enlargement  and  tender- 
ness and  occasional  attacks  of  pain.  This  chronic  pain  and  swelling  gradually/ 
subside,  intercurrent  subacute  attacks  becoming  less  pronounced,  the  testicle 
ultimately  becoming  wasted.  This  wasting  may  affect  only  a  portion  of  the 
gland,  producing  asymmetry;  but  usually  the  whole  organ  is  affected,  there 
remaining  when  the  process  is  completed  a  body  of  varying  shape,  about  the 
size  of  a  Lima  bean  or  even  smaller  than  this. 

Malignant  disease  frequently  follows  severe  testicular  trauma. 

Prognosis  is  then  always  guarded,  and  becomes  less  favorable  in  proportion 
to  the  severity  and  the  persistence  of  inflammation. 

Treatment. — Even  the  mildest  forms  of  contusion  of  the  testicle  should 
not  be  neglected,  since  exceptionally  they  are  followed  by  chronic  inflammation 
and  atrophy.  In  severe  injuries,  shock  and  syncope  are  treated  in  accordance 
with  general  principles,  and  the  agonizing  pain  is  controlled  by  the  injection 
of  morphine.  The  patient  should  be  placed  upon  his  back,  with  the  pelvis 
elevated  and  the  scrotum  supported  either  by  a  pillow  placed  against  the  peri- 
neum;  or  by  a  triangular  handkerchief  bandage,  the  base  of  which  is  passed 


314  GENITO-URINARY  SURGERY 

beneath  the  scrotum,  while  its  ends  are  secured  to  a  band  about  the  waist; 
or  by  a  bridge  of  adhesive  plaster  stretched  from  thigh  to  thigh.  To  the  injured 
testicle  cloths  kept  constantly  wet  in  lead  water  and  alcohol  are  appHed,  omitting 
oiled  silk,  since  this  prevents  the  cooling  effect  of  evaporation.  A  small  ice- 
bag  is  even  more  efficient,  and  can  be  used  for  three  or  four  days,  a  piece  of 
lint  being  kept  between  its  surface  and  the  skin  of  the  scrotum.  If  cold  makes 
the  pain  more  severe,  hot  compresses  wrung  out  of  dilute  lead  water  and  renewed 
every  fifteen  minutes  may  be  employed,  or  lint  soaked  in  this  same  lotion  may 
be  applied,  and  over  it  may  be  placed  a  hot-water  bag.  The  bowels  should 
be  opened  freely. 

When  the  swelling  is  so  rapid  and  extensive  as  to  threaten  the  vitality  of 
the  parts  there  should  be  no  hesitation  in  cutting  down  upon  and  securing  the 
bleeding  points.  Discoloration  incident  to  scrotal  blood  effusion  should  not  be 
mistaken  for  gangrene.  The  patient  should  be  kept  confined  to  bed  until  the 
active  inflammatory  symptoms  have  subsided,  and  may  then  be  allowed  to 
get  up,  wearing  the  pressure  suspensory  bandage  described  in  the  section  on 
the  treatment  of  epididymitis.  This  bandage  should  be  worn  for  months,  and 
the  patient  should  be  cautioned  against  occupations  or  exercises  liable  to  cause 
a  recurrence  of  inflammation,  such  as  those  requiring  long  standing  or  much 
straining.  Small  doses  of  potassium  iodide  and  application  of  mild  counter- 
irritants  to  the  skin  of  the  scrotum  are  serviceable  in  relieving  the  chronic 
congestion  which  is  liable  to  follow  upon  injury  of  the  testis,  and  which  is  certain 
to  result  in  deposition  of  fibrous  tissue  and  subsequent  wasting  of  secreting 
structure. 

Epididymo-orchitis  from  Strain. — This  inflammation  is  properly  con- 
sidered under  the  head  of  contusion,  since  in  a  certain  proportion  of  cases  the 
symptoms  are  due  to  pinching  or  bruising  of  the  testicle. 

There  develops,  without  a  preceding  urethritis  and  without  obvious  cause, 
a  swelling  which  closely  resembles  in  symptomatology  and  course  either  epididy- 
mitis secondary  to  gonorrhoea  or  traumatic  epididymo-orchitis. 

Terrillon  records  the  case  of  a  man  who,  in  making  a  violent  lifting  effort, 
experienced  a  sudden  pain  in  the  left  testicle  so  acute  that  he  fainted.  There 
was  no  contusion,  no  blood  effusion.  The  testis  was  fixed  in  the  left  groin, 
and  exhibited  the  tenderness,  swelling,  and  pain  of  acute  orchitis.  Symptoms 
simulating  localized  peritonitis  supervened,  and  lasted  for  eight  days.  The 
patient  was  confined  to  bed  for  three  weeks.  At  the  end  of  that  time  the 
testicle  had  atrophied  until  it  was  one-fifth  its  natural  size;  it  was  so  tender 
that  palpation  could  not  be  endured.  The  thigh  was  flexed,  adducted,  and 
rotated  inward.  As  two  months'  further  rest  did  not  relieve  the  symptoms, 
castration  was  performed. 

From  careful  observation  of  more  than  a  dozen  of  these  cases  we  believe 
that  etiologically  they  can  be  classified  as  follows:  1.  Epididymo-orchitis  due 
to  a  violent  contraction  of  the  cremaster  muscle,  which  by  suddenly  jerking 
the  testicle  against  the  pillars  of  the  external  ring  causes  a  bruising  of  the 
former,  often  accompanied  by  rupture  of  the  veins;  this  is  called  "  whip-snap  " 
action.  "When  the  external  ring  is  patulous  the  testicle  may  be  drawn  within 
its  grip  and  may  be  further  bruised  in  this  way.     2.  Epididymo-orchitis  from 


SURGERY  OF  THE  TESTICLES  315 

rupture  of  the  veins.  As  a  result  of  violent  muscular  effort  and  increased 
intra-abdominal  pressure  the  often-dilated,  valveless  veins  of  the  cord  become 
enormously  congested.  This  congestion  is  further  increased  by  compression  on 
the  part  of  fibres  which  Roux  states  pass  from  the  rectus  muscle  to  the  inner 
lip  of  the  iliac  crest.  These  fibres  participating  in  the  general  muscular  con- 
traction pinch  the  cord  against  the  fibrous  circumference  of  the  external  ab- 
dominal ring.  Rupture  of  vessels  and  bleeding  into  the  cord,  the  epididymis, 
or  possibly  the  substance  of  the  testis  result.  3.  Epididymo-orchitis  from 
m.asked  lesion.  In  a  certain  number  of  cases  we  have  been  able  to  trace  the 
inflammation  to  infection  passing  from  the  posterior  urethra  along  the  vas; 
strain  and  possible  slight  contusion  were  undoubtedly  favoring  factors.  The 
symptomatology  and  course  of  the  inflammation  were  not  different  from  those 
commonly  observed  in  cases  of  chronic  posterior  urethritis.  Twice  we  have 
observed  acute  tuberculous  epididymitis  develop  suddenly  after  muscular  effort. 

In  accordance  with  the  cause  of  the  inflammation,  variations  in  its  clinical 
course  are  observed.  There  may  be  an  acute  epididymo-orchitis,  such  as  that 
which  follows  ordinary  traumatism,  temporarily  prostrating  the  patient  and 
keeping  him  in  bed  for  days  or  weeks.  The  inflammation  may  be  limited  almost 
entirely  to  the  epididymis  and  may  run  its  course  in  a  few  days.  Or  there  may 
be  an  almost  painless  enlargement,  neither  confining  the  patient  to  bed  nor 
interfering  with  his  occupation,  provided  a  suspensory  bandage  is  worn. 

The  left  testicle  is  more  frequently  involved  than  the  right;  this  is  what 
would  naturally  be  expected  if  the  theory  of  venous  rupture  from  pressure  be 
correct. 

Prognosis. — The  prognosis  of  epididymo-orchitis  from  strain  is  much  better 
than  when  external  violence  is  the  cause.  When  the  lesion  is  simply  hemor- 
rhagic, the  blood  being  found  in  the  lower  part  of  the  cord  and  about  the 
epididymis,  with  but  slight  congestion  of  the  testicle,  atrophy  of  this  organ  is 
not  to  be  feared.  When  the  inflammatory  attack  is  hmited  chiefly  to  the  testis 
and  is  severe,  there  is  wasting. 

Treatment. — The  treatment  is  that  appropriate  to  contusion  of  the  testicle. 
Even  in  the  comparatively  painless  cases  a  properly  fitted  pressure  suspensory 
bandage  should  be  worn  for  a  long  period. 

Wounds  of  the  Testicle.— Incised  wounds  of  the  testicle  if  kept  clean 
heal  promptly.  Such  injuries  are  extremely  rare,  except  in  the  course  of  surgical 
operations,  particularly  those  undertaken  for  the  purpose  of  establishing  diag- 
nosis. If  the  proper  tunic  is  opened  and  the  testis  found  healthy,  the  albuginea 
should  be  neatly  apposed  with  catgut  sutures  and  the  external  wound  closed. 
Infection  may  be  followed  by  prolapse  of  the  secreting  substance  of  the  cTiand 
unless  drainage  is  promptly  established.  In  tuberculous  or  syphilitic  cases 
the  so-called  benign  fungus  may  follow  incised  wounds. 

Punctured  wounds  are  usually  inflicted  by  a  misdirected  trocar.  Provided 
the  instrument  is  clean,  they  are  harmless.  If  a  dirty  instrument  infects  the 
testicle,  diffuse  acute  orchitis  may  develop,  with  total  destruction  of  the  secreting 
substance. 

Lacerated  and  gunshot  wounds  should  be  treated  by  thorough  cleansing 
and  abundant  drainage.     When  it  is  evident  that  the  testicle  is  extensively 


316  GENITO-URINARY  SURGERY 

bruised,  castration  is  the  best  treatment.  When  both  testicles  are  involved  in 
gunshot  wounds  every  effort  should  be  made  ta  preserve  even  small  portions  of 
the  secreting  substances  of  the  glands.  This  is  usually  practicable  if  the  wound 
is  kept  clean.  If  suppuration  takes  place,  complete  atrophy  will  probably  be 
the  result. 

Otis  states  that  atrophy  and  neuralgia  are  common  sequelae  of  gunshot 
wounds  of  the  testes  when  castration  has  not  been  performed. 

On  the  first  sign  of  infection  after  an  attempt  has  been  made  to  close  a 
wound  of  the  testicle,  the  stitches  should  be  removed,  the  wound  widely  opened, 
and  drainage  secured  by  a  gauze  wick. 

After  cleansing  and  closure  of  a  wounded  testis  and  the  application  of  a 
proper  dressing,  the  part  should  be  elevated,  and  should  be  subjected  to  mod- 
erate pressure  by  means  of  a  crossed-of-the-perineum  bandage.  Outside  the 
antiseptic  dressing  applied  immediately  over  the  wound  is  placed  a  sufficient 
quantity  of  cotton  or  crumped  gauze  to  equalize  the  pressure  of  the  bandage. 
The  bandage  should  be  seven  yards  long  and  three  or  four  inches  wide.  It  is 
fixed  by  a  circular  turn  about  the  pelvis,  placed  beneath  the  iliac  crest.  It  is 
then  carried  downward  along  the  right  groin,  across  the  perineum,  around  the 
back  of  the  left  thigh  at  the  position  of  the  iliofemoral  fold,  upward  over  the 
trochanter  and  below  the  crest  of  the  ilium,  completely  around  the  body  until 
it  is  just  above  the  left  trochanter,  down  along  the  left  groin,  across  the  peri- 
neum, around  the  back  of  the  right  thigh  at  the  iliofemoral  fold,  and  upward 
and  forward  over  the  right  trochanter.  These  turns  are  repeated,  alternating 
occasionally  with  circular  turns  about  the  pelvis,  until  a  firm  dressing  is  formed 
which  entirely  covers  in  the  scrotum  and  perineum. 

INFECTIONS  OF  THE  TESTICLE 

Infection  of  the  testicle  may  be  acute  or  chronic.  The  acute  infections  are 
secondary  to  posterior  urethral  infections,  usually  gonococcic,  or  develop  as 
complications  or  sequelae  of  a  general  infection,  such  as  mumps,  typhoid,  grip, 
malaria,  or  exanthemata.  There  is  also  a  gouty  orchitis.  The  chronic  infec- 
tions are  usually  tuberculous  or  syphilitic. 

URETHRAL  EPIDIDYMITIS 

Gonorrhoeal  urethritis  is  the  commonest  cause  of  epididymitis,  the  inflam- 
mation being  almost  entirely  confined  to  the  epididymis.  The  vaginal  tunic  is 
commonly  inflamed,  as  is  shown  by  the  development  of  acute  hydrocele,  which 
may  greatly  increase  the  bulk  of  the  swelling. 

Epididymitis  is  a  common  sequel  of  instrumental  urethritis — for  instance, 
that  following  the  use  of  the  lithotrite,  or  frequent  catheterization.  It  some- 
times complicates  gouty  urethritis. 

It  is  an  expression  of  infection  carried  by  the  vas,  and  may  therefore 
complicate  any  form  of  urethritis. 

Symptoms. — The  first  suggestion  of  trouble  may  be  felt  in  the  groin  or  in  the 
epididymis  itself.  In  the  former  case  an  aching,  sometimes  a  neuralgic,  pain 
is  felt  along  the  line  of  the  groin,  often  running  down  to  the  testicle,  and  made 
much  worse  by  standing  or  walking.    If  the  cord  be  taken  between  the  thumb 


SURGERY  OF  THE  TESTICLES 


317 


and  finger  and  rolled  so  that  its  constituents  afe  separated,  the  vas  deferens 
may  be  found  somewhat  enlarged  and  tender  on  pressure.  Sometimes  there  is 
neither  tenderness  nor  enlargement  of  the  cord  to  be  detected.  If  the  inflam- 
mation progresses,  the  epididymis  becomes  involved  in  one  or  two  days  at  most. 

Frequently  the  disease  develops  without  any  previous  manifestations  of 
involvement  of  the  cord.  Suddenly  there  will  then  be  felt  in  the  testicle  a 
fixed,  dragging  pain.  The  epididymis  increases  rapidly  in  size,  the  scrotal 
covering  of  the  affected  testicle  becomes  oedematous  and  purplish  in  color,  and 
pain  is  at  times  almost  unbearable  and  of  a  peculiar  sickening  quality  which 
renders  it  diagnostic.  If  there  be  an  anterior  urethral  discharge  this  is  gener- 
ally lessened;  sometimes  it  entirely  ceases  for  the  time. 

On  palpation  the  epididymis  is  found  to  be  sensitive  and  so  much  enlarged 
that  it  envelops  the  testicle  above,  behind,  and  below  in  a  swelling  more  volumi- 
nous than  the  gland  itself  (Fig.  160). 
In  the  great  majority  of  cases  the 
inflammation  extends  to  the  tunica 
vaginalis  and  occasions  an  effusion  of 
fluid,  giving  rise  to  an  acute  hydro- 
cele; the  latter  entirely  masks  the 
testicles  so  that  on  palpation  a  fluc- 
tuating tumor  is.  felt  in  front, 
which  is  often  incorrectly  diagnosed 
as  a  swollen  testicle,  whilst  behind 
is  the  enlarged,  exquisitely  tender 
epididymis. 

The  patient,  unless  the  testicle  is 
supported,  walks  with  his  body  bent 
forward  and  his  legs  straddling. 
When  he  stands,  free  return  of  blood 
is  prevented  by  the  dragging  of  the 
tumor  upon  the  spermatic  vessels; 
this  increases  the  tension  and  by  additional  pressure  upon  the  nerves  greatly 
aggravates  the  pain  which  sometimes*  spreads  reflexly  to  the  bladder,  perineum, 
tectum,  back,  abdomen,  thighs,  and  even  to  the  thoracic  region,  and  is  almost 
unbearable. 

There  are  usually  rigors,  fever,  and  great  mental  anxiety  and  depression. 
Sometimes  acute  epididymitis  in  its  onset  is  characterized  by  symptoms  so 
violent  and  apparently  so  disconnected  from  the  testicle  as  to  occasion  a  mis- 
taken diagnosis.  In  these  cases  there  will  develop,  often  in  connection  with  a 
posterior  urethritis  fanned  to  new  intensity,  violent  abdominal  pains,  accom- 
panied by  tympany  and  extreme  sensitiveness  in  the  lower  part  of  the  belly; 
fever  runs  high,  and  nausea,  green  vomiting,  and  collapse  may  follow.  These 
symptoms  subside  almost  as  quickly  as  they  develop,  and  are  followed  by  the 
ordinary  symptoms  of  epididymitis.  The  disease  usually  reaches  its  height  in 
three  to  five  days. 

The  clinical  course  of  epididymitis  varies  greatly  in  individual  cases.  Some 
patients  experience  only  moderate  dragging  pain,  which  does  not  incapacitate 


Fig.  160. — Showing  the  size  and  relative  position 
of  the  testicle  and  epididymis  in  acute  epididymitis. 
H,  testis;  N .h.,  epididymis;  5,  cord.  A,  the  swelling 
is  most  marked  about  the '  head  of  the  epididymis. 
B,  the  swelling  is  most  marked  about  the  tail. 
(Kaufmann.) 


318 


GENITO-URINARY  SURGERY 


them,  and  exhibit  a  somewhat  sharply  circumscribed  tumor  in  the  tail  of  the 
epididymis,  with  possibly  slight  hydrocele  (Fig.  161),  and  a  little  reddening 
and  induration  of  the  scrotal  skin  overlying  the  seat  of  hardening.  In  the 
majority  of  cases  the  pain,  though  severe,  is  relieved  by  a  properly  fitting  sus- 
pensory bandage,  and  the  patient  is  not  forced  to  take  to  his  bed.  The  swelling 
is,  however,  usually  very  marked.  Redness  and  oedema  of  the  posterior  aspect 
of  the  scrotum  may  be  present ;  hydrocele  when  present  may  be  general  or  may 
be  encysted  from  inflammatory  adhesions.  On  rectal  examination  a  thickened 
tender  mass  corresponding  in  position  with  the  ampulla  of  the  vas  and  the  seminal 
vesicle  can  usually  be  felt.  When  the  funicular  portion  of  the  tunica  vaginalis 
has  not  been  obliterated  there  may  be  formed  a  true  hydrocele  of  the  cord. 

Finally  there  are  cases  which,  though  not  exhibiting  especially  severe  local 
symptoms,  are  characterized  by  reflexes  which  so  strongly  suggest  general  peri- 
tonitis that  they  usually  occasion  grave  anxiety  unless  a  rectal  examination  be. 
made.     Exceptionally,  when  the  testicle  and  its  epididymis  are  not  normally 


Fig.  161. — Epididymitis,  right  side. 

placed,  an  acute  epididymitis  may  lead  to  an  error  in  diagnosis.  Thus,  when 
the  testicle  is  retained  within  the  inguinal  canal  the  early  symptoms  may  readily 
simulate  those  of  a  strangulated  hernia.  An  examination  of  the  scrotum,  by 
showing  the  absence  of  the  testicle  from  its  normal  position,  would  at  once 
suggest  the  diagnosis. 

The  pathological  changes  incident  to  epididymitis  consist  of  a  catarrhal 
inflammation  of  the  vas  and  epididymis,  associated  in  severe  cases  with  oedema 
and  round-cell  infiltration  of  its  walls  and  the  surrounding  loose  connective 
tissue.  Multiple  foci  of  gonococcus-containing  pus  are  present  in  the  more 
serious  cases,  more  often  in  the  tail  than  in  the  head  of  the  epididymis.  The 
serous  surface  of  the  organ  may  be  covered  with  a  diphtheroid  membrane. 

Prognosis. — The  prognosis  of  epididymitis  is  good,  although  cases  are  re- 
ported in  which  life  has  been  lost  from  extension  of  the  inflammation  to  the 


SURGERY  OF  THE  TESTICLES  319 

peritoneum.  These  are  extremely  rare.  The  disease  may  undergo  complete 
resolution;  exceptionally  suppuration  occurs.  Commonly  the  inflammatory  in- 
filtrate, instead  of  being  completely  absorbed,  organizes  in  part,  and  forms  a 
hard  nodule  in  the  tail  of  the  epididymis  which  obliterates  the  efferent  duct 
of  the  testicle.  Exceptionally  there  is  a  permanent  thickening  of  the  entire 
epididymis.     The  hydrocele  may  become  chronic. 

Suppuration  is  denoted  by  increased  severity  of  the  local  inflammatory 
symptoms,  by  rigors  and  sweats,  and  finally  by  fluctuation.  On  opening  the 
abscess,  prolapse  of  the  entire  epididymis  sometimes  occurs;  when  the  suppu- 
rative inflammation  has  involved  the  testicle  proper,  this  may  be  entirely 
destroyed  in  a  short  time  by  rapid  extension  of  the  trouble;  or  the  suppurative 
process  may  become  chronic  and  slowly  extend,  finally  resulting  in  destruction 
of  the  gland.  In  pure  gonococcic  infection  the  testis  is  rarely  involved  in 
epididymitis,  and  hence  is  not  materially  altered  even  though  its  efferent  duct 
is  entirely  blocked.  Very  rarely  after  the  cure  of  a  specially  severe  epididymitis 
the  testicle  slowly  atrophies.  In  this  event  it  is  probable  that  the  inflammation 
had  extended  to  its  structure,  and  as  the  infiltrate  became  organized  and  ex- 
ercised pressure  the  glandular  substance  atrophied  and  was  absorbed.'  Even 
though  the  inflammation  undergoes  apparent  resolution  it  may  favor  the  develop- 
ment of  latent  tuberculosis. 

The  prognosis  in  regard  to  fertility  is,  of  course,  good  when  but  one  testicle 
is  affected,  though  even  then  it  has  been  noted  that  spermatozoa  disappear 
entirely  from  the  semen  during  the  height  of  an  attack.  When  the  epididymitis 
is  bilateral  the  prognosis  must  be  more  guarded,  though  many  of  these  cases 
recover  with  functionating  testicles.  In  a  certain  proportion,  however,  especially 
in  those  not  carefully  treated,  the  epididymis  of  both  sides  becomes  obliterated 
and  the  patients  remain  sterile.  When  the  sterility  is  of  long  standing  it  can 
be  helped  only  by  operation.  (See  "  Sterility.")  Impotence  is  never  a  direct 
consequence  of  epididymitis. 

Pure  gonorrhoeal  epididymitis  is  much  less  likely  to  suppurate  than  that 
which  results  from  instrumental  infection.  Suppuration  is  comparatively  com- 
mon in  instrumental  epididymitis. 

The  hard  nodule  left  in  the  globus  minor  after  gonorrhoeal  epididymitis 
usually  persists  indefinitely,  nor  is  this  persistence  always  proportionate  to  the 
original  attack.  Except  during  or  shortly  after  an  acute  inflammatory  period, 
treatment  of  these  fibrous  nodules  is  futile.  The  nodulation  probably  renders 
the  individual  sterile  so  far  as  that  single  gland  is  concerned,  but  it  does  not 
usually  attract  his  attention  or  arouse  his  anxiety,  and  is  therefore  not  the  cause 
of  hypochondriasis  or  neurasthenia,  as  otherwise  it  would  be  in  the  greater 
number  of  cases.  With  the  exception  of  the  testes,  all  glands  atrophy  when 
their  ducts  are  completely  obstructed.  Adult  testes  with  vasa  congenitally  absent 
form  apparently  normal  and  freely  motile  spermatozoa.  Nor  does  sudden 
occlusion  of  the  vas  at  any  time  of  life  affect  the  nutrition  or  function  of 
the  gland. 

Treatment. — Prophylaxis  consists  in  the  wise  treatment  of  the  posterior 
urethral  infection,  and,  until  it  is  cured,  the  avoidance  of  intercourse,  constipa- 
tion, food  surfeit,  surface  chilling,  muscular  strain,  or  excesses  of  any  kind.    The 


320 


GENITO-URINARY  SURGERY 


wearing  of  a  suspensory  bandage  is  advisable.  The  passage  of  instruments 
through  the  posterior  urethra  should  be  accomplished  with  the  greatest  possible 
gentleness;  the  administration  of  full  doses  of  atropine  before  such  instru- 
mentation is  said  to  reduce  the  liability  to  this  complication.  On  the  first 
prodromal  symptoms  the  patient  should  be  put  to  bed,  the  bowels  should  be 
freely  opened,  preferably  by  a  saline,  the  testicles  should  be  wrapped  in  lead 
water  and  dilute  alcohol,  and  elevated,  and  hot  compresses  and  a  hot-water  bag 
should  be  applied  to  the  inguinal  region.  These  measures  will  usually  limit 
the  inflammation  to  a  funiculitis,  especially  when  the  treatment  appropriate 
to  a  posterior  urethritis  has  been  prescribed. 

The  treatment  of  gonococcal  epididymitis  may  be  .either  nonoperative  or 
operative;  the  former  may  be  further  subdivided  according  to  whether  or  not 
the  patient  is  confined  to  bed.  The  gireat  majority  of  cases  can  be  treated  in 
an  ambulatory  manner,  though  undoubtedly  the  attack  is  shortened  by  rest 
in  bed;  sociological  considerations  must  often  determine  the  method  to  be  used 
rather  than  the  best  interests  of  the  patient.  Operative  treatment  most  promptly 
relieves  pain,  and  is  followed  by  prompt  subsidence  of  the  inflammation.  But 
by  division  of  the  duct  of  the  epididymis  the  method  is  apt  to  sterilize  the 

patient,  so  far  as  the  affected  side  is  concerned. 
For  this  reason  it  should  only  be  advised  in 
cases  of  the  more  severe  grades,  when  rest  in 
bed  for  two  or  three  days  has  failed  to  check 
the  inflammation,  or  where  there  seems  to  be 
danger  of  destruction  of  the  testicle  through 
abscess  formation. 

Ambulatory  Treatment. — The  first  essen- 
tial of  this  form  of  treatment  is  the  application 
of  a  suspensory  of  appropriate  design.  The 
bandage  employed  is  a  modification  of  the 
Langlebert-Horand,  and  brings  to  the  relief  of  inflammation  the  most  potent 
remedies  at  the  command  of  the  surgeon;  namely,  heat,  moisture,  rest,  and 
pressure  (Fig.  162).  The  body  of  the  suspensory  is  made  up  of  mackintosh, 
which  is,  in  turn,  lined  with  stout  cloth.  The  bag  of  the  bandage  is  shallow, 
and  at  the  sides  are  gores  which  are  provided  with  eyelets  and  laces.  When  a 
bandage  of  proper  size  is  applied  and  strapped  tightly  it  not  only  presses  the 
testicles  upward  against  the  soft  parts  lying  anterior  to  and  below  the  pubes, 
but  by  the  lacings  also  exerts  lateral  pressure,  so  that  these  glands  are  every- 
where evenly  supported.  The  method  of  applying  this  bandage  is  as  foHows: 
The  patient  is  placed  in  a  recumbent  position,  and  the  testicles  and  scrotum 
are  held  up  for  four  or  five  minutes,  thus  reducing  congestion  as  much  as 
possible  by  position.  The  whole  scrotum  is  then  enveloped  in  a  thick  sheet 
of  absorbent  cotton  or  wool.  Outside  of  this  the  suspensory  bandage  is  applied. 
It  is  strapped  on  tightly,  and  is  then  laced  at  the  sides.  When  the  appliance  is 
properly  fitted,  relief  of  pain  is  almost  immediate  and  is  usually  permanent, 
and  resolution  takes  place  promptly. 

An  ointment  may  be  used  in  addition  to  the  suspensory  with  considerable 
advantage.    The  most  valuable  substance  for  such  application  is  guaiacol,  from 


Fig.  162. — Epididymitis  suspensory 
bandage. 


SURGERY  OF  THE  TESTICLES  321 

10  to  25  per  cent,  of  which  may  be  used.  Its  penetrating  odor  makes  it 
objectionable  to  many,  however,  and  may  render  its  use  undesirable.  Ichthyol 
ointment,  5  per  cent.,  or  an  ointment  containing  ichthyol,  belladonna,  and  mer- 
cury, may  then  be  employed. 

When  the  acute  inflammatory  symptoms  have  subsided — i.e.,  when  the  pain 
has  lessened  and  is  severe  only  upon  motion,  and  the  epididymis  and  the  sur- 
rounding cellular  tissue  form  a  large  solid  mass — pressure  is  always  indicated, 
whatever  has  been  the  previous  method  of  treatment.  This  may  be  applied  by 
means  of  a  suspensory  bandage,  as  already  ■  described,  or  through  the  medium 
of  a  strip  of  thin  rubber  dam  eight  to  ten  inches  long  and  half  as  wide.  The 
testicle  is  tightly  encircled  in  this  bandage,  the  final  turn  of  which  is  secured 
by  a  strip  of  adhesive  plaster.  The  dressing  is  most  easily  applied  by  fastening 
the  upper  margin  of  the  bandage  with  adhesive  plaster,  before  its  application, 
at  such  a  point  that  slight  pressure  is  made  on  the  cord,  so  that  obstruction 
hyperaemia  shall  exist  in  the  parts  covered  by  the  rubber.  The  dressing  is  then 
applied  by  stretching  the  rubber  sufficiently  to  let  it  slip  over  the  testicle.  The 
lower  portion  of  the  dam  is  then  laid  smoothly  over  the  swollen  organ,  and 
secured  below  with  a  second  piece  of  adhesive  plaster.  A  suspensory  then  com- 
pletes the  dressing. 

When  all  inflammatory  swelling  has  disappeared,  but  an  indurated  nodule 
persists,  the  pressure  suspensory  bandage  should  still  be  employed  in  conjunction 
with  an  ointment  made  of  belladonna  ointment  and  mercuric  ointment  equal 
parts,  while  internally  five  grains  of  potassium  iodide  should  be  given  three 
times  a  day. 

"  Bed  "  treatment  is  required  by  the  more  severe  type  of  the  disease, 
both  on  account  of  the  constitutional  reaction  and  on  account  of  the  local  pain. 
The  diet  should  be  restricted,  and  the  bowels  moved  two  or  three  times  a  day. 
If  rest  and. sleep  are  prevented  by  the  pain,  morphine  should  be  given  in  sufficient 
quantity  to  secure  reasonable  comfort. 

The  scrotum  with  the  inflamed  testicle  should  be  elevated  by  means  of  a 
pillow,  handkerchief  bandage,  or  adhesive  plaster  support  (Fig.  163),  and 
swathed  in  gauze  kept  wet  with  a  saturated  solution  of  magnesium  sulphate, 
or  with  the  following  solution: 

IJ     Tinct.  aconiti,  Ei 

Alcohol, 

Liq.   plumbi  subacetatis,  dil., 

Aquse,  aa  f§  ii. 
M.  S. — For  external  use. 

In  some  cases  guaiacol  ointment  seems  to  act  better  than  either  of  these 
lotions. 

Operative  Treatment. — Under  this  heading  are  grouped  tapping  of  symp- 
tomatic hydroceles,  puncture  of  the  epididymis,  and  epididymotomy. 

Tapping  of  Hydrocele. — This  procedure  is  so  simple  that  it  might  properly 
be  considered  under  one  of  the  previous  captions.  It  is  performed  by  the  inser- 
tion of  a  hollow  needle,  16  to  22  gauge,  through  a  puncture  wound  in  the  skin, 
and  is  indicated  whenever  a  recognizable  quantity  of  fluid  is  present.  The 
amount  of  relief  derived  from  this  simple  procedure  is  sometimes  very  great. 
21 


322 


GEXITO-URIXARY  SURGERY 


Puncture  of  the  Epididymis. — ]Much  benefit  sometimes  follows  the  simple 
insertion  of  a  cataract  knife  or  Hagedorn  needle  into  the  region  of  greatest 
innltraiton,  usually  at  the  back  of  the  scrotum  and  at  about  the  middle  of  the 
epididymis.  The  puncture  should  be  preceded  by  an  injection  of  eucaine  solu- 
tion. A  few  drops  of  serum  usually  escape  after  the  knife  is  withdrawn,  and 
there  is  almost  immediate  lessening  of  pain.  The  operation  need  not  confine  the 
patient  to  his  bed. 

Epididymotomy. — This  operation,  popularized  by  Hagner,  is  best  performed 
under  a  general  anaesthetic  (preferably  nitrous  oxide),  though  when  due  care 
is  taken  to  block  the  ner\-es  to  the  testicle  by  infiltration  of  the  cord  local 
anaesthesia  ma}^  be  used  "^ith  satisfaction. 

The  operation  is  performed  by  making  a  sufficiently  long  incision  on  the  outer 
side  of  the  scrotum  for  the  dehvery  of  the  testicle,  the  tunica  vaginalis  being 


Fig.  163. — Adhesive  strip  for  the  support  of  scrotum.  Narrow  strips  of  adhesive  plaster 
run  up  on  the  abdomen  on  each  side  of  the  scrotum  to  keep  the  broad  strip  in  place;  lint  has 
been  applied  to  the  portion  not  adhering  to  the  thighs  (under  surface  shown).    • 

opened  freely.  After  delivery  the  epididymis  is  inspected  and  palpated  to  deter- 
mine the  points  of  greatest  induration.  These  are  generally  found  in  the  tail 
of  the  organ.  A  cataract  knife  is  used  to  puncture  the  areas  selected,  the  tracts 
made  with  the  knife  being  enlarged  with  a  probe  should  pus  escape.  The 
injection  of  solutions  of  arg\Tol  (20  per  cent.)  or  protargol  (2  to  5  per  cent.) 
into  these  tracts  has  seemed  to  be  of  advantage  in  some  cases.  The  operation 
is  concluded  by  the  return  of  the  testicle  to  the  scrotum  and  the  suture  of  the 
wound  about  a  drain  of  rubber  dam,  down  to  the  puncture  points  in  the  epidid- 
}Tnis.    The  drain  is  allowed  to  remain  for  three  to  six  days. 

After  epididymotomy.  pain  and  fever  disappear  wath  great  rapidity,  while 
the  swelling  of  the  epididymis  and  the  residual  induration  go  more  quickly  and 
more  completely  than  \\-ith  other  methods  of  treatment.  Patients  are  confined 
to  bed  after  the  operation  for  from  four  days  to  two  weeks. 


SURGERY  OF  THE  TESTICLES  323 

The  treatment  of  all  forms  of  epididymitis  due  to  extension  of  inflammation 
from  the  posterior  urethra  is  conducted  on  the  lines  laid  down  in  regard  to  the 
gonorrhoeal  variety.  Urethritis  which  is  intensified  by  gout  should  be  subjected 
to  antilithsemic  remedies,  and  appropriate  diet  and  hygiene  should  be  ordered. 
The  harassing  recurring  epididymitis  from  which  prostatics  who  are  compelled 
to  pass  the  catheter  suffer  should  be  prevented  by  vasectomy,  and  the  operation 
should  be  performed  for  the  relief  of  all  forms  of  recurring  epididymitis  of  urethral 
origin  when  the  patient  is  past  the  procreative  age.  For  the  operative  cure  of 
sterility  following  double  obliterating  epididymitis,  see  page  452. 

EPIDIDYMO-ORCHITIS    COMPLICATING   ACUTE    INFECTIOUS 

DISEASES 

Under  this  general  heading  are  included  orchitis  of  mumps,  variola,  typhoid, 
malaria,  scarlatina,  influenza,  and  possibly  gout.  Inflammation  in  most  of 
these  cases  is  of  pure  haematogenous  origin,  dependent  upon  toxic  substances 
circulating  in  the  blood.  It  apparently  attacks  primarily  and  most  severely  the 
testis.  When  the  disease  develops  in  its  acute  form  the  symptoms  are  even  more 
marked  than  those  of  acute  epididymitis.  In  the  latter  affection  the  bulk  of 
the  tumor  is  formed  by  the  epididymis,  which  partly  envelops  the  testis  as  would 
a  hand  a  small  kidney.  In  orchitis  the  main  swelling  is  formed  by  the  testis, 
this  gland,  even  though  enormously  swollen,  maintaining  its  normal  form;  the 
epididymis,  if  uninvolved,  is  stretched  as  a  narrow  band  along  its  posterior 
border.  The  general  testicular  sensibility  is  greatly  increased.  Acute  hydrocele 
may  occur  coincidently  with  the  swelling  of  the  testis,  but  is  much  less  common 
than  when  the  epididymis  is  involved.  Exceptionally  suppuration  ensues;  this 
is  nearly  always  preceded  by  great  oedema  and  discoloration  of  the  scrotum  and 
by  pronounced  constitutional  symptoms. 

The  differential  diagnosis  between  orchitis  and  epididymitis  is  based  mainly 
upon  the  form  of  the  swelling.  When  the  tissues  of  the  scrotum  become  markedly 
oedematous,  and  particularly  when  hydrocele  develops,  a  differential  diagnosis 
may  be  impossible;  nor  is  this  of  cardinal  importance. 

Orchitis  Complicating  Mumps. — Inflammation  of  the  testicle  is  sometimes 
the  sole  expression  of  mumps;  it  runs  an  acute  course,  terminating  in  a  few  days 
or  a  few  weeks. 

It  may  be  ushered  in  by  a  rise  of  temperature,  and  generally  develops  from 
the  fourth  to  the  sixth  day  of  the  disease.  As  a  rule,  only  one  testis  is  involved. 
Catrin,  basing  his  conclusion  on  a  study  of  one  hundred  and  fifty-nine  cases  of 
mumps,  states  that  orchitis  occurs  in  one  out  of  three  cases,  usuafly  develops 
after  the  parotitis,  and  begins  in  the  epididymis,  the  body  of  the  gland  being 
subsequently  attacked.  In  a  certain  number  of  cases  after  a  period  of  atrophy 
and  loss  of  consistency  the  testicle  regains  its  original  volume  and  firmness. 
If  both  testes  become  involved  the  inflammation  is  usually  consecutive. 

The  inflammation  of  this  form  of  orchitis  begins  in  the  gland  and  not  in  the 
epididymis,  and  incurable  atrophy  is  a  much  commoner  sequel  than  is  generally 
conceded.  Hornus  observed  a  fatal  case  of  orchitis  consecutive  to  mumps. 
Death  was  caused  by  peritonitis,  the  testicles  having  been  absolutely  destroyed 
and  converted  into  a  purulent  collection. 


324  GENITO-URINARY  SURGERY 

As  to  the  etiology  of  the  testicular  affection,  Kocher  states  that  orchitis 
after  mumps  is  urethral,  the  specific  inflammation  excited  by  the  organism 
first  involving  the  urethral  mucous  membrane  and  then  extending  along  the 
vas.  If  this  were  true,  we  should  expect  the  inflammation  to  develop  first  in 
the  epididymis,  as  in  the  case  of  most  inflammations  of  urethral  origin.  With 
the  exception  of  Catrin,  authors  generally  teach  that  the  testis  is  primarily 
involved.  The  symptoms  of  mumps  orchitis  are  pain,  swelling,  exquisite  tender- 
ness, and  fever  of  moderate  degree.  Exceptionally  the  attack  is  ushered  in 
with  typical  symptoms  of  acute  peritonitis — i.e.,  vomiting,  constipation,  tym- 
pany, and  peritoneal  tenderness;  still  more  rarely  by  acute  nephritis  with 
uraemia. 

Diagnosis. — The  diagnosis  is  founded  upon  associated  symptoms  of  paro- 
titis, or,  in  the  rare  cases  when  these  are  latent  or  absent,  upon  the  possibility 
of  contagion  and  the  exclusion  of  other  sufficient  causes  of  inflammation. 

Prognosis. — This  should  always  be  guarded.  In  light  attacks  characterized 
by  moderate  swelling  the  prognosis  is  doubtless  favorable.  In  severe  attacks 
with  pronounced  general  symptoms,  and  especially  when  the  attack  is  prolonged, 
atrophy  is  always  to  be  dreaded. 

Treatment. — The  measures  already  described  as  appropriate  to  orchitis 
and  epididymitis  are  indicated  when  the  testis  becomes  inflamed  as  an  .expres- 
sion of  mumps. 

As  a  prophylactic  treatment  in  all  cases  of  parotitis  it  is  well  to  support 
the  scrotum  by  a  soft  flannel  binder  or  a  suspensory  bandage,  in  accordance 
with  the  age  of  the  patient.  The  comparatively  unyielding  tunica  albuginea 
subjects  the  secreting  substance  of  the  testis  to  fatal  pressure  when  inflammation 
is  pronounced  or  is  of  long  standing.  This  can  be  reheved  at  once  by  incision 
or  puncture.  The  profession  has  been  deterred  from  this  form  of  intervention  by 
the  fear  of  hernia  testis — i.e.,  extrusion  of  the  secreting  substance  of  the  testicle. 
WTien  this  has  occurred  it  has  been  in  consequence  of  infection;  even  though  a 
certain  amount  of  testicular  substance  should  be  lost  as  a  result  of  incision,  it  is 
probable  that  the  ultimate  functional  power  of  the  organ  would  be  better  than 
it  is  when  tension  has  been  unrelieved. 

Typhoid  orchitis  is  commonest  before  the  age  of  puberty.  As  a  rule,  it 
is  mild  in  type  and  occurs  during  convalescence.  The  etiology  of  this  condition 
is  somtimes  dependent  on  venous  thrombosis,  though  it  may  be  the  result  of  in- 
fection from  the  urethra  or  through  the  agency  of  the  blood.  The  t5^hoid 
bacillus  has  been  found  in  suppurative  cases.    Atrophy  is  rare. 

Malarial  Orchitis. — This  form  of  inflammation  is  chronic  in  type,  with 
acute  paroxysms,  sometimes  recurring  regularly.  In  one  case  we  noted  acute 
pain  and  exquisite  tenderness  developing  daily  with  the  regularity  that  char- 
acterizes a  quotidian  type  of  malaria.  The  condition  yielded  promptly  and 
completely  to  full  doses  of  quinine. 

Le  Dentu  states  that  the  testicle  slowly  increases  in  size,  becoming  elephan- 
tiastic.  He  describes  a  form  of  overgrowth  associated  with  elephantiasis  of  the 
scrotum  and  evidently  dependent  upon  involvement  of  the  lymphatic  system. 
This  is  characterized  by  recurrent  erysipelatoid  attacks,  with  gradual  deposi- 


SURGERY  OF  THE  TESTICLES  325 

tion  of  partially  organized  fibrous  tissue.  It  is  probable  that  this  is  not  malarial 
orchitis,  but  a  distinct  affection. 

The  principal  diagnostic  features  of  malarial  orchitis  are  the  recurrence  of 
attacks  and  the  absence  of  other  sufficient  cause  for  the  symptoms.  Examina- 
tion of  the  blood  and  full  dosage  with  quinine  will  establish  the  diagnosis  and 
relieve  the  condition. 

Orchitis  following  tonsillitis  is  an  expression  of  infection  which  may 
be  haematogenous  or  may  be  carried  from  the  urethra.  The  course  of  the  affec- 
tion is  similar  to  that  of  orchitis  complicating  mumps.  The  disease  lasts  two 
or  three  weeks  and  usually  terminates  in  resolution,  but  may  suppurate  or  be- 
come chronic,  in  either  case  ultimately  causing  atrophy. 

Gouty  orchitis  is  found  associated  with  the  usual  phenomena  of  gout.  It 
may  be  acute  or  chronic  in  type,  and  is  likely  to  be  persistent.  It  may,  how- 
ever, alternate  with  other  gouty  symptoms,  disappearing  with  the  arthritis  and 
reappearing  as  the  latter  subsides.  It  is  prone  to  relapse,  occurring  in  sudden 
seizures,  and  may  be  transferred  from  one  testicle  to  the  other.  True  gouty 
orchitis  is  quite  different  from  the  epididymitis  of  urethral  origin  observed  in 
gouty  persons.  It  occurs  after  middle  life,  and  affects  primarily  and  chiefly 
the  testis,  rarely  extending  to  the  epididymis. 

Orchitis  following  small-pox,  scarlatina,  or  influenza  has  no  pathog- 
nomonic features.  It  is  simply  a  local  expression  of  a  general  infection,  due 
either  to  lodgement  of  microorganisms  circulating  in  the  blood  or  to  extension 
by  means  of  a  phlebitis,  especially  of  the  spermatic  veins. 

Traumatic  orchitis  has  been  already  discussed. 

By  whatever  cause  orchitis  or  orchi-epididymitis  is  excited,  the  lesions,  symp- 
toms, and  terminations  are  practically  the  same,  with  minor  differences  de- 
pendent upon  a  difference  in  the  virulence  of  the  infection  and  upon  varying 
individual  power  of  resistance.  The  distinction  between  inflammations  of  ure- 
thral and  those  of  haematogenous  origin  is  important  mainly  from  a  therapeutic 
standpoint,  since  a  posterior  urethritis  if  present  should  receive  attention. 

The  inflammation  may  terminate  in  complete  resolution  with  restoration  of 
physiological  function,  in  chronic  inflammation  followed  by  atrophy  and  loss 
of  function,  or  in  abscess  often  complicated  by  fungus  of  the  testicle.  Gangrene 
is  a  rare  complication  occurring  in  debilitated  patients.  Exceptionally  the  in- 
flammation extends  along  the  cord,  occasioning  pelvic  cellulitis  and  peritonitis. 
We  believe,  however,  that  most  of  the  reported  cases  of  this  extension  are  in 
reality  instances  of  suppuration  of  the  seminal  vesicles.  The  initial  cause  of 
chronic  inflammation  is  usually  a  preceding  acute  orchitis,  although  underlying 
this  there  is  often  a  constitutional  dyscrasia.  Either  the  testicle  becomes  in- 
durated and  completely  atrophies,  or  suppuration  takes  place,  producing  multiple 
abscess. 

Treatment. — Acute  orchitis  is  treated  by  the  remedies  and  applications  de- 
scribed as  appropriate  to  gonorrhoeal  epididymitis.  The  indications  are  met  by 
rest  in  bed,  elevation  of  the  pelvis  and  the  testicles,  the  application  of  evaporat- 
ing lotions  or  the  ice-bag,  or  hot  fomentations,  according  to  the  severity  of  the 
inflammation,  securing  a  free  movement  of  the  bowels,  and  the  administration 
of  febrifuges  and  diuretics,  and  of  morphine  hypodermically  in  sufficient  doses 
to  control  the  severe  pain. 


326  GENITO-URINARY  SURGERY 

If  the  pain  is  -so  intense  that  safe  doses  of  morphine  will  not  relieve  it,  the 
tunica  albuginea  may  be  punctured.  The  punctures  should  be  made  with  a 
straight  cataract  knife;  the}'  ma}'  be  multiple  and  may  be  repeated  several 
times.  The  importance  of  guarding  against  infection  is  evident.  Abscesses 
should  be  opened  and  drained  by  gauze  packing;  rheumatic  and  gouty  cases 
should  receive  appropriate  constitutional  treatment,  and  invariably  on  the  sub- 
sidence of  acute  inflammation  the  general  treatment  of  the  patient  should  be 
tonic  and  supporting. 

As  soon  as  patients  are  able  to  leave  bed,  and  when  the  inflammation  is 
moderately  severe  this  should  not  be  under  two  or  three  weeks,  a  carefully 
fitted  pressure  suspensory  bandage  should  be  worn,  preferably  that  described  in 
the  treatment  of  gonorrhoeal  epididymitis,  and  this  should  be  continued  for 
months  or  until  the  testicle  returns  to  its  normal  condition.  At  the  same  time 
a  slightly  stimulating  ointment  applied  to  the  scrotal  skin  will  be  serviceable. 
One  reason  that  acute  orchitis  and  orchi-epididymitis  run  into  the  chronic  form 
and  produce  slow  destruction  of  the  secreting  portion  of  the  testes  is  that  pa- 
tients are  allowed  to  be  up  and  about  before  blood-vessels  have  regained  their 
tonicity,  and  hence  there  results  a  condition  of  chronic  congestion  in  a  previously 
inflamed  organ.  Prolonged  rest  in  bed  and  an  accurately  fitting  pressure 
bandage  are  the  means  of  treatment  which  offer  most  hope  of  avoiding  this 
complication. 

Abscess  of  the  Testicle 

Reference  has  been  already  made  to  abscess  as  a  comparatively  rare  termi- 
nation of  acute  or  chronic  orchitis  and  epididymitis.  In  tuberculous,  malig- 
nant, or  syphilitic  degeneration  of  the  testicles  pus-formation  is  common.  In 
gonorrhoea  and  mumps  it  is  rarer  than  in  other  acute  infectious  diseases.  It 
is  probably  most  frequent  in  the  epididymo-orchitis  which  develops  in  old  men 
in  consequence  of  catheter  urethritis  (Fig.  164). 

A  small  abscess  having  formed  in  the  testis,  it  may  become  encysted,  un- 
dergoing caseous  degeneration  (Fig.  165);  or  it  may  spread  beneath  the  tunica 
albuginea,  invohdng  the  whole  testis  and  causing  sloughing,  followed  by  many 
openings;  or  may  rupture  into  the  tunica  vaginalis,  causing  suppuration  of  this 
sac  and  ultimately  pointing  externally;  or  the  abscess  may  reach  the  surface 
without  rupturing  into  the  cavity  of  the  tunica  vaginalis,  inflammatory  ad- 
hesions gluing  all  the  tissues  together  before  the  pus  breaks  through  the  tunica 
albuginea. 

Sometimes  the  abscess  when  centrally  placed  may  remain  quiescent  for  an 
indefinite  period,  occasionally  exhibiting  acute  exacerbations. 

The  symptoms  of  suppuration  are  those  of  an  aggravated  orchitis.  Usually 
there  is  fever  and  the  cedematous  swelling  of  the  scrotum  becomes  more  pro- 
nounced. Following  incision  or  spontaneous  evacuation,  fungus  of  the  testicle 
may  develop,  the  whole  of  the  secreting  substance  of  the  gland  being  extruded. 

Treatment. — Early  free  incision,  followed  by  irrigation  and  gauze  drainage, 
is  the  treatment  best  calculated  to  relieve  tension,  and  therefore  to  lessen  the 
danger  of  acute  tissue  necrosis.  Healing  is  usually  prompt.  When  the  whole 
testis  is  riddled  A\ith  abscesses,  or  when  sloughing  has  taken  place,  castration 
is  the  operation  of  choice. 


SURGERY  OF  THE  TESTICLES 


327 


Fig.  164. — Suppuration  epididymo  orchitis.  E,  ab- 
scess of  epididymis;  T,  abscess  cavities  in  body  of  testicle; 
5,  spermatic  cord.  (No.  1687,  Laboratory  of  Surgica' 
Pathologi',   University  of  Pennsylvania.) 


Wall  of  abscess  cavity 


Testicle  proper  Cavity  of 

epididymis  abscess 


Fig.   165. — Abscess  of  epididymis.     (No.   3217,  Laborator>- of  Surgical 
Pathology,  University  of  Pennsylvania. 


328  GENITO-URINARY  SURGERY 

Fungus  or  Hernia  of  the  Testicle. — The  older  writers  described  a  hernia 
testis  apparently  due  to  simple  infection  following,  for  instance,  such  a  pro- 
cedure as  puncture  of  the  tunica  albuginea  for  relief  of  pain  in  a  gonorrhoeal 
epididymitis.  We  have  once  encountered  such  a  condition  which  was  neither 
tuberculous  nor  syphilitic,  but  was  an  instance  of  sloughing  testis,  in  which 
the  devitalized  tissues  gradually  escaped  through  an  infected  and  bruised 
trochar  opening. 

Fungus  which  accompanies  suppurative  or  sloughing  processes  may  be 
made  up  entirely  of  granulation-tissue.  This  is  always  the  case  in  the  parietal 
form  of  the  affection.  In  the  glandular  or  deep  form  the  tubular  structure  of 
the  testis  is  often  extruded,  though  absence  of  the  tubules  in  the  slough  and 
discharge  does  not  prove  that  the  granulations  do  not  grow  from  the  gland. 

The  tuberculous  fungus  may  be  superficial  or  deep,  and  is  made  up  of  ex- 
uberant granulations  from  the  walls  of  an  abscess.  These  protrude  through 
openings  in  the  scrotum  which  exhibit  indurated,  chronically  inflamed,  gradu- 
ally contracting  borders;  they  appear  as  yellowish-red,  painless,  cauliflower-like 
growths,  overlapping  the  scrotal  defect,  rarely  larger  than  the  end  of  the  thumb, 
though  in  the  glandular  variety  the  greater  part  of  the  testicular  substance  .may 
be  extruded. 

The  syphilitic  fungus  grows  from  the  walls  of  a  discharging  gumma;  it  may 
be  intra-  or  extra-glandular;  it  rarely  attains  the  size  of  the  tuberculous  fungus. 

The  malignant  fungus  (fungus  haematodes)  is  in  reality  a  new  growth  which 
has  broken  through  the  tissues  of  the  scrotum. 

Treatment. — This  depends  upon  the  cause  and  the  variety  of  the  fungus. 
Syphilitic  cases  are  cured  by  an  appropriate  constitutional  treatment,  supple- 
mented by  cutting  away  the  exuberant  granulations  and  dressing  the  wound 
with  sterile  gauze.  Tuberculous  cases,  if  superficial,  may  be  cured  by  touch- 
ing with  caustic  potash  and  dressing  with  iodoform  gauze.  If  deep,  they  should 
be  opened,  curetted  from  the  bottom,  and  packed;  if  persistent  and  associated 
with  extensive  degeneration  of  the  testicle,  castration  should  be  performed. 
Fungus  haematodes  (malignant)  should  be  treated  by  castration. 

The  fungus  which  complicates  simple  abscess  or  sloughing,  and  which 
springs  from  the  glandular  substance,  being  made  up  of  granulation-tissue  and 
sometimes  of  seminiferous  tubules,  should  be  opened  and  curetted  and  the  re- 
sulting wound  packed  with  gauze. 

TUBERCULOSIS  OF  THE  TESTICLE 

Tuberculous  inflammation  first  attacking  the  epididymis  may  develop  very 
exceptionally  as  a  sudden  outbreak  with  all  the  local  and  general  symptoms 
of  acute  inflammation,  leaving  on  subsidence  an  irregular  nodulation  character- 
istic of  tuberculosis;  usually  as  a  slow,  apparently  non-inflammatory,  almost 
painless  formation  of  tuberculous  nodules. 

The  infection  may  reach  the  testicles  through  the  blood-channels  or  may 
extend  along  the  vas.  Occasionally  the  testicles  are  affected  during  the  evolution 
of  a  general  miliary  tuberculosis.  The  lodgement  of  the  ttibercle  bacili  may  be 
primary  in  the  epididymis,  or  the  infection  may  be  secondary  to  prostatic,  vesi- 
cal, or  renal  tuberculosis,  or  to  foci  of  the  disease  in  other  parts  of  the  body. 


SURGERY  OF  THE  TESTICLES 


329 


So  far  as  clinical  evidence  goes,  the  epididymis  appears  to  be  a  frequent 
seat  of  primary  tuberculosis;  from  this  organ  as  the  starting-point  the  disease 
extends  along  the  genito-urinary  tract.  Saltzmann  defends  the  theory  of  the 
entrance  of  the  bacilli  by  way  of  the  blood-vessels  on  the  ground  that  the  arteries 
of  the  epididymis  are  smaller  and  more  tortuous  than  those  of  the  testis  or  of 
the  vas,  and  that  thus  bacilli  floating  in  the  blood  are  more  liable  to  be  lodged. 

It  is  possible  that  infection  may  take  place  during  coitus.  Verneuil  strongly 
defends  this  theory.  He  demonstrates  the  presence  of  tubercle  bacilli  in  the 
discharges  of  patients  suffering  from  uterine  tuberculosis,  and  cites  cases  in 
which  the  disease  appeared  in  persons  of  perfectly  healthy  constitution  after 
sexual  intercourse  with  women  so  affected.  This  belief  in  immediate  tuberculous 
contagion  is  sufficiently  well  grounded  to  justify  a  careful  examination  of 
uterine  and  vaginal  discharges  in  suspected  cases,  and,  when  bacilli  are  found, 
to  make  it  desirable  to  suggest  means  of  prophylaxis. 


Fig.  166. — Tuberculous  epididymitis.  E,  epi- 
didymis involved  in  the  caseating  tuberculous 
process,  T,  body  of  testicle  free  from  disease.  (No. 
500,  Laboratory^  of  Surgical  Pathology,  University 
of   Pennsylvania!) 

Tubercle  bacilli  have  been  found  in  the  healthy  testis  and  epididymis.  It 
is  also  proved  that  these  organisms  may  circulate  in  the  blood  without  obtaining 
lodgement  in  the  tissues,  and  consequently  without  working  deleteriously  upon 
the  system  until  acute  inflammation,  particularly  that  following  traumatism, 
produces  a  local  lessening  of  resistance  which  favors  the  lodgement  and  multi- 
plication of  the  microorganisms.  This  has  been  shown  experimentally  by  in- 
traperitoneal injection  of  tuberculous  sputum  followed  by  contusion  of  the 
testis,  and  suggests  that  an  acute  gonorrhoeal  epididymitis  or  an  orchitis  in- 
cident to  traumatism  may  predispose  to  tuberculous  infiltration. 

In  the  large  majority  of  cases  tuberculous  infiltration  is  first  noted  in  the 
head  of  the  epididymis,  appearing  as  indolent  nodules  which  sooner  or  later 
undergo  cheesy  degeneration  (Fig.  166).  The  epididymis  becomes  irregularly 
infiltrated,  and  the  vas  thickened,  hard,  and  nodular.  The  disease  also  ex- 
tends in  the  direction  of  the  testis,  and  not  infrequently  the  vaginal  tunic  is 


330 


GENITO-URINARY  SURGERY 


involved.  When  the  testis  is  infected,  similar  nodules  develop  and  show  a 
central  degeneration,  extending  at  the  same  time  peripherally,  and  finally  form- 
ing a  comparatively  large  cavity  (Fig.  167). 

Though  from  clinical  examination  in  the  vast  majority  of  cases  tuberculosis 
seems  primarily  to  involve  the  epididymis,  entirely  sparing  the  testis,  Reclus 
has  shown  by  post-mortem  dissection  that  in  the  later  stages  of  the  disease 
both  epididymis  and  testis  are  involved  in  more  than  three-fourths  of  the  cases. 

Symptoms. — Tuberculous  epididymo-orchitis  may  develop  abruptly  or  in- 
sidiously, or  may  be  preceded  by  certain  highly  characteristic  prodromal 
symptoms. 

The  abrupt  development  of  the  disease  commonly  is  dependent  upon  slight 
trauma  or  extension  of  inflammation  from  posterior  urethritis.    The  symptoms 


Spermatic  cord 


Entire  testicle  the  site 
of  a  tuberculous  proc- 
ess  in    the  state  of 
caseation 


Fig.    167. — Tuberculosis    of    the    testicle.      (Laboratory    of 
Surgical  Pathology,  University  of  Pennsylvania.) 

are  practically  the  same  as  those  of  traumatic  orchitis  or  of  gonorrhoea!  epididy- 
mitis. There  are  the  characteristic  sickening  pain,  effusion  into  the  tunica 
vaginalis  and  the  cellular  tissues  about  the  epididymis,  and  general  oedema. 
Instead  of  subsiding  in  the  course  of  a  few  days  or  one  or  two  weeks,  the  local 
swelling  persists,  though  pain  may  be  almost  entirely  relieved.  In  a  few  weeks 
fluctuation  may  be  detected,  and  one  or  more  sinuses  form,  discharging  cheesy 
pus,  or  the  formation  of  fistulae  may  be  a  late  development. 

The  inflammation  is  commonly  an  epididymo-orchitis,  and  is  often  bilateral. 
It  attacks  by  preference  young  adults,  and  is  first  lodged  in  the  epididymis, 
the  outlines  of  which  are  so  obscured  by  a  large  bossed  swelling  that  the  loop 
formed  by  the  vas  deferens  cannot  be  felt  (Reclus);  the  vas  is  often  infiltrated, 
and  there  may  be  tuberculous  involvement  of  the  other  genito-urinary  organs. 


SURGERY  OF  THE  TESTICLES  331 

particularly  the  prostate  and  seminal  vesicles.  Except  during  the  period  of  acute 
outbreak  there  is  little  or  no  pain.  Hydrocele  generally  develops  in  connection 
with  this  form  of  tuberculosis,  and  is  likely  to  be  of  the  agglutinative  type. 
In  the  discharge  from  the  sinuses  tubercle  bacilli  may  be  found. 

The  usual  insidious  form  of  the  disease  is  characterized  by  the  slow,  painless 
formation  of  nodules  either  in  the  epididymis  or  in  the  testicle,  or  in  both  these 
organs.  Frequently  there  are  absolutely  no  symptoms,  the  patient  detect- 
ing the  overgrowth  accidentally.  Sometimes  there  is  a  sense  of  dragging 
weight,  or  there  are  reflex  disturbances,  such  as  frequent  emissions  or  sexual 
hyperaesthesia,  which  lead  to  examination  of  the  part  and  discovery  of  the 
swelling. 

In  the  chronic  forms  of  tuberculous  involvement  of  the  testis  and  epididy- 
mis suppuration  and  abscess-formation  develop  much  more  slowly  than  in  the 
acute.  Even  large  infiltrations  become  encapsulated  and  absorbed,  leaving 
simply  irregular  fibroid  nodulations.  We  have  under  observation  a  few  cases 
of  tuberculous  epididymo-orchitis  which  have  lasted  from  ten  to  twenty  years, 
and  in  place  of  softening  and  breaking  down  have  undergone  a  steady  fibroid 
change.  When  fistulas  are  formed,  usually  in  the  lower  posterior  part  of  the 
scrotum,  they  continue  to  discharge  a  thin  serous  fluid,  often  containing  broken- 
down  granulations,  until  the  degenerated  tissue  is  entirely  eliminated;  they 
then  heal,  unless  there  is  extension  of  infiltration. 

The  form  of  the  disease  ushered  in  by  prodromata  is  probably  not  primary ; 
i.e.,  there  is  a  pre-existing  tuberculous  involvement  of  some  other  portion  of  the 
genito-urinary  tract.  The  prodromal  symptoms  are — (1)  A  painless,  moderate 
■urethritis,  characterized  by  a  scanty,  turbid,  mucopurulent  discharge,  notice- 
able only  in  the  morning.  This  discharge  comes  and  goes  apparently  without 
cause,  and  is  uninfluenced  by  treatment.  (2)  Frequent  urination.  (3)  A 
hypersensitive  condition  of  the  prostatic  urethra,  particularly  to  instrumental 
examination  and  irritating  injections.  (4)  Terminal  haematuria.  These  symp- 
toms may  last  weeks  or  months  before  appreciable  development  of  lesions  in 
the  testis  or  the  epididymis,  and  indicate  tuberculous  involvement  of  the  vesi- 
cles, vasal  ampullae,  or  posterior  urethra. 

Diagnosis. — The  diagnosis  of  acute  tuberculous  epididymo-orchitis  is  based 
on — (1)  The  apparently  causeless  outbreak  of  acute  inflammation.  When 
traumatism,  mumps,  gonorrhoea,  syphilis,  and  the  various  infectious  diseases 
can  be  excluded,  tuberculosis  should  be  suspected.  (2)  The  presence  of  tuber- 
culous infiltration  in  the  prostate  or  seminal  vesicles  or  evidences  of  infection 
in  other  parts  of  the  body.  (3)  Persistence  of  swelling  after  the  pain  and 
other  symptoms  of  acute  inflammation  have  subsided.  (4)  Formation  of  nod- 
ules, particularly  in  the  region  of  the  epididymis,  which  soften  and  break  down, 
leaving  fistulae,  in  the  discharge  of  which  may  be  found  tubercle  bacilli. 

Acute  tuberculous  epididymitis  commonly  develops  in  young  adults  of  lym- 
phatic temperament  who  have  a  tuberculous  family  history.  The  pain  and 
swelling  are  somewhat  less  marked  than  in  cases  of  gonorrhoeal  epididymitis,  for 
instance.  It  must  be  confessed  that  in  the  first  one  or  two  weeks  of  an  attack 
it  may  be  impossible  to  establish  a  diagnosis.     The  formation  of  suppurating 


332  GENITO-URINARY  SURGERY 

nodules  is,  however,  characteristic.  The  cord  is  soon  involved,  becoming  thick- 
ened and  irregularly  bosselated. 

The  diagnosis  of  chronic  tuberculous  epididymo-orchitis  is  based  upon  a 
tuberculous  history,  the  painless  noninflammatory  development  of  infiltration, 
particularly  in  the  head  of  the  epididymis,  the  association  with  nongonorrhoeal 
urethral  discharge,  frequent  urination,  and  haematuria,  the  discovery  of  indura- 
tion or  nodulation  of  the  seminal  vesicles  or  prostate,  the  gradual  extension  of 
the  infiltration  to  the  entire  epididymis  and  to  the  cord,  often  forming  an  ir- 
regular tumor  much  larger  than  the  testis,  and  finally  upon  the  tuberculin  test 
and  bacteriological  examination.  When  there  is  an  associated  hydrocele  (and 
this  is  common),  injection  of  this  fluid  into  the  peritoneal  cavity  of  rabbits  may 
cause  the  development  of  miliary  nodules.  The  urethral  discharges  should  be 
carefully  examined  for  tubercle  bacilli.  It  must  be  remembered  that  it  is  possi- 
ble for  gonorrhoeal  epididymitis  to  develop  and  run  its  typical  course  in  the 
tuberculous  subject  without  subsequent  tuberculous  infiltration  of  the  epididymis 
or  testis. 

Differential  diagnosis  between  the  tuberculous  nodule  and  the  induration  fol- 
lowing gonorrhoea  is  based  upon  the  history  of  a  preceding  acute  urethritis  and 
upon  the  fact  that  the  gonorrhoeal  induration  is  found  in  the  tail  of  the  epididy- 
mis, while  the  tuberculous  nodule  is  usually  in  the  head.  The  gonorrhoeal  nodule 
exhibits  no  tendency  toward  extension,  does  not  mask  the  outlines  of  the 
epididymis,  and  is  not  associated  with  palpable  lesions  of  the  cord. 

The  differential  diagnosis  between  acute  gonorrhoeal  epididymitis  and  acute 
tuberculous  epididymitis  in  the  absence  of  other  tuberculous  lesions  must  be 
held  in  abeyance  until  the  tuberculous  process  develops  with  characteristic 
features.    The  finding  of  the  gonococcus  does  not  necessarily  exclude  tubercle. 

Prognosis. — It  has  been  already  stated  that  tuberculous  nodules  may  be- 
come encapsulated  and  absorbed,  leaving  a  mass  of  fibrous  tissue  to  mark 
their  position.  This  does  not  necessarily  indicate  that  a  definite  cure  has  been 
accomplished,  since  under  favoring  circumstances  the  tuberculous  foci  may 
again  become  active  and  with  greatly  increased  virulence.  Yet  when  the  infec- 
tion is  located  only  in  the  epididymis  or  testis,  spontaneous  cure  may  result 
from  this  process  of  encapsulation. 

The  course  of  the  case  will  be  unfavorable  in  direct  ratio  to  ( 1 )  the  rapidity 
of  development;  (2)  the  extent  of- involvement  of  the  gland;  (3)  the  tendency 
to  become  bilateral;    (4)  the  association  with  diffuse  urogenital  tuberculosis. 

In  any  event  it  cannot  be  too  strongly  emphasized  that,  as  in  all  other  forms 
of  surgical  tuberculosis,  the  prognosis  is  extremely  grave  if  the  patient  is  neces- 
sarily intrusted  to  the  vis  medicatrix  naturcc. 

When  the  tuberculous  process  is  lodged  solely  in  the  epididymis  or  the 
testis  and  is  subjected  to  prompt  surgical  treatment,  the  prognosis  is  favorable. 
When  the  affection  is  bilateral,  involving  the  cord,  seminal  vesicles,  and  prostate, 
surgical  intervention  promises  little  success;  the  main  dependence  must  be 
placed  on  constitutional  hygienic  treatment. 

Treatment. — 1.  Palliative  Treatment. — When  a  patient  suffering  from 
tuberculous  epididymo-orchitis.  will  not  submit  to  operation,  or  when  the  disease 
is  so  wide-spread  that  its  complete  removal  is  impossible,  hygienic  measures 


SURGERY  OF  THE  TESTICLES  333 

adapted  to  tuberculous  patients  generally  are  indicated.  The  most  efficient 
of  these  is  probably  out-door  life  in  a  suitable  climate.  The  testicles  should  be 
protected  and  supported  by  the  pressure  suspensory  bandage  described  in  the 
treatment  of  gonorrhoeal  epididymitis  or  by  a  well-fitting  jock-strap. 

2.  Radical  treatment,  when  the  disease  is  strictly  localized — i.e.,  when  it 
appears  in  the  form  of  small,  separate  nodules  or  foci  of  caseation — may  con- 
sist in  epididymectomy,  or  in  incision,  followed  by  vigorous  scraping  of  the  in- 
fected tissues  and  packing  with  iodoform  gauze. 

Excision  of  the  epididymis  or  a  portion  of  the  testis  is  indicated  when  there 
is  reason  to  believe  that  a  considerable  part  of  the  gland  may  be  safely  left. 
An  incision  is  made  on  the  outer  posterior  scrotal  surface  and  the  epididymis  is 
cut  away  from  below  upward,  the  blood-vessels  lying  along  its  inner  border  being 
spared.    So  much  of  the  vas  as  is  readily  accessible  should  be  removed. 

Injections  of  ten  per  cent,  emulsion  of  iodoform  in  glycerine  have  given 
excellent  results,  and  are  particularly  indicated  when  the  disease  is  bilateral  and 
cannot  be  eradicated  by  erasion  or  excision  of  the  epididymis.  From  five  to 
fifteen  drops  of  this  mixture  should  be  employed  for  one  treatment,  and  should 
be  driven  directly  into  the  infiltrated  mass,  the  needle  being  introduced  at  sev- 
eral points  and  two  or  three  drops  deposited  at  each.  The  injections  are  repeated 
every  third  or  fourth  day,  depending  upon  the  violence  of  the  reaction. 

There  can  be  no  question  as  to  the  permanence  of  many  cures  reported  from 
the  injection  treatment,  though  as  a  result  the  epididymis  becomes  hopelessly 
obliterated. 

Castration  is  the  final  operation  applicable  to  advanced  cases.  This  treat- 
ment is  indicated  when  the  tuberculous  involvement  is  too  extensive  to  be  re- 
moved by  erasion  as  a  partial  operation,  and  when  other  tuberculous  lesions 
are  either  absent  or  but  moderate  in  extent. 

When  castration  is  performed,  not  only  the  testicle  but  all  infiltrated  skin 
and  cellular  tissue  should  be  removed.  The  cord  should  be  divided  high  up, 
and  the  vas  should  be  followed  beyond  the  limits  of  nodulation  or  infiltration, 
even  into  the  pelvis,  if  this  is  required  by  the  extent  of  the  disease.  When  the 
vas  is  infiltrated  through  its  entire  length,  the  incision  for  castration  should  be 
extended  from  the  scrotum  upward  parallel  to  Poupart's  ligament  and  down  to 
the  peritoneum,  which  should  be  separated  from  the  lateral  walls  of  the  bladder 
by  the  finger,  using  the  vas  deferens  as  a  guide,  until  the  top  of  the  seminal 
vesicle  is  reached.  The  vas  is  divided  at  this  point  and  extracted.  Roux  sug- 
gests that  when  the  ampulla  of  the  vas,  the  prostate,  and  the  seminal  vesicles 
are  involved,  a  semilunar  incision  should  be  made  in  front  of  the  anus,  the  rectum 
separated  from  the  prostate,  a  transverse  incision  made  in  the  fascia  covering 
the  seminal  vesicles  and  vasa,  and  the  diseased  structures  peeled  off  from  the 
bladder  and.  removed.  Of  eleven  cases  thus  treated  by  Von  Biinger  eight  were 
free  from  recurrence  after  more  than  five  years;  one  died  of  miliary  tuberculosis. 

Haas  has  shown  that  double  castration  in  cases  of  tuberculosis  of  the  testicle 
is  followed  in  over  fifty  per  cent,  of  cases  by  radical  cure,  and  does  not  cause 
mental  or  nervous  disturbances.  Subsequent  to  unilateral  castration  the  disease 
appeared  in  the  remaining  testicle  in  one-fourth  of  the  cases.  Following  any 
operation  the  hygienic  and  dietetic  treatment  appropriate  to  tuberculosis  should 
be  continued  for  a  long  time. 


334 


GENITO-URINARY  SURGERY 


SYPHILIS  OF  THE  TESTIS  AND  EPIDIDYMIS 

Either  portion  of  the  testicle  may  be  the  site  of  syphilitic  infection,  and  in 
either  portion  the  disease  may  manifest  itself  either  as  a  diffuse  interstitial  proc- 
ess or  by  the  production  of  gummata.  Though  the.  onset  is  typically  insidi- 
ous, in  occasional  instances  the  signs  of  acute  inflammation  are  present. 

The  tumor  formed  by  gummata  is  nearly  always  painless,  except  from  its 
weight.  This  infiltration  may  soften  and  break  down,  forming  fistulae  or  fungus, 
or  may  lead  to  atrophy  of  the  gland. 

The  diagnosis  of  syphilitic  epididymitis  from  the  tuberculous  affection  is 
based  on  the  density  and  the  sharper  demarcation  of  the  syphilitic  nodules,  on 
the  history  of  the  case  and  the  effect  of  constitutional  treatment  and  the  Wasser- 
mann  reaction.  Acute  S3^philitic  orchitis  is  characterized  by  the  primary  devel- 
opment of  the  affection  in  the  testis,  by  the  evenness  and  hardness  of  the  tumor, 


^G 


Fig.  168. — Gumma  of  testicle.  G,  gumma;  5,  sper- 
matic cord.  (No.  3541,  Laboratory  of  Surgical  Pathology, 
University  of  Pennsylvania.) 

by  the  history  of  syphilis,  by  the  absence  of  other  sufficient  cause  for  the  disease, 
and  by  the  effect  of  constitutional  treatment.  Gummatous  orchitis  differs  from 
tuberculous  disease  in  forming  a  larger,  denser  tumor  before  softening  occurs, 
one  that  commonly  involves  the  entire  testis,  and  forming  on  its  surface  ridges 
or  nodules.  It  never  reaches  the  size  of  a  man's  fist  before  breaking  down  (Fig. 
168).  It  is  commonly  masked  in  part  by  an  associated  hydrocele  and  is  often 
bilateral.  Gummatous  fistulse  lead  down  to  the  testicle  and  open  on  the  anterior 
surface  of  the  scrotum,  differing  in  both  these  respects  from  the  tuberculous 
fistulse,  which  originate  in  the  epididymis,  and  commonly  open  on  the  side  of  the 
scrotum.  The  diagnosis  between  syphilitic  and  tuberculous  orchitis  may  be 
impossible  from  inspection  and  palpation.  The  distinction  of  syphilitic  sarcocele 
from  hsematoma  is  made  on  the  history  of  the  development  of  the  tumor  or  upon 
the  result  of  aspiration. 


SURGERY  OF  THE  TESTICLES 


335 


TUMORS  OF  THE  TESTICLE 

The  usual  tumor  of  the  testicle  is  the  teratoma.  A  variety  of  neoplasms 
have  been  described,  resulting  in  a  bewildering  classification;  incomplete  section- 
ing of  the  tumors  and  the  preponderance  of  a  single  element  in  large  growths 
are  probably  responsible  for  the  misconceptions,  the  complex  nature  of  the 
tumors  being  unrecognized  in  many  cases. 

The  following  statements  are  based  largely  on  Ewing's  ^  monograph: 

A  few  simple  tumors  have  been  described  as  springing  from  the  testicle. 
They  are  all  so  rare  as  to  be  of  no  clinical  importance. 

Fibromata  are  of  slow  growth  and  symptomless.  Less  than  a  dozen  have 
been  reported,  none  in  recent  literature. 


Fig.  169. — Lymphosarcoma  of  the  testicle  (bilateral). 

Chondroma,  Myxoma,  Lipoma. — These  tumors  probably  exist  only  as  parts 
of  teratomata. 

Myoma. — A  single  case  of  undoubted  leiomyoma  has  been  reported,  by 
Trelat.    Rhabdomyoma  seems  to  occur  only  as  a  part  of  a  teratoma. 

Adenoma. — The  majority  of  the  growths  which  have  been  described  as 
adenomata  have  probably  been  teratomata,  yet  these  tumors  are  occasionally 
encountered,  usually  of  small  size,  originating  from  the  tubules  of  the  testis,  es- 
pecially in  undescended  testicles. 

Sarcoma. — Primary  lymphosarcoma  is  a  rare  tumor,  though  more  common 
than  any  of  the  previously  mentioned  neoplasms.  It  is  generally  bilateral  (Fig. 
169),  runs  a  rapid  course,  metastasizing  to  the  skin  as  a  rule.     The  existence 

^  Ewing,  J.:  "Teratoma  Testis  and  Its  Derivatives,"  Surg.,  Gynec,  and  Obstet., 
March,  1911,  p.  230. 


336  GENITO-URINARY  SURGERY 

of  spindle-cell  sarcoma  is  questioned ;  the  occurrence  of  small  round-cell  sarcoma 
as  a  simple  tumor  is  also  doubtful  (Fig.  170). 

Carcinoma. — Cancerous  tissue  is  found  in  almost  all  teratomata  of  the  testi- 
cle. It  also  occurs  in  many  cases  in  which  a  careful  search  has  failed  to  dis- 
cover teratomatous  elements.  Yet  the  general  structure  and  the  appearance  of 
the  cells  in  these  tumors  so  closely  resemble  those  found  in  the  teratomata  that 
the  theory  has  been  advanced  that  they  are  in  reality  one-sided  developments 
of  teratomata;  this  particularly  in  regard  to  adenocarcinoma  and  large  alveolar 
carcinoma.  The  scirrhous  and  medullary  forms  as  described  by  Langhans  seem 
to  have  a  better  claim  to  be  considered  pure  carcinoma  (Figs.  171  and  172). 


Soft  vascular 
sarcomatous  tissue 


Fibrous    trabeculas 


Fig.  170. — Sarcoma  (teratoma)    of   the  testicle.      (No.  623,    Labo- 
ratory  of  Surgical   Pathology,   University   of   Pennsylvania.) 

Teratoma. — These  mixed  tumors  arise  typically,  if  not  always,  from  the 
region  of  the  rete  testis.  Trauma  seems  to  be  an  etiological  factor  in  a  fair 
percentage  of  cases. 

More  than  one-half  the  cases  of  teratoma  of  the  testicle  develop  between  the 
thirtieth  and  the  fortieth  years.  The  growth  may  be  slow  or  rapid;  if  the  latter, 
the  size  of  a  child's  head  may  be,  rarely,  attained. 

The  tumor  usually  corresponds  to  the  form  of  the  testis  until  it  has  thinned 
or  perforated  the  albuginea,  when  it  becomes  irregular  and  nodulated.  The 
tunica  vaginalis  is  partly  obliterated  by  adhesions;  the  portions  not  thus  closed 
are  filled  with  blood-stained  serum.    As  the  tumor  proliferates  it  may  involve 


SURGERY  OF  THE  TESTICLES 


337 


and  destroy  the  skin,  forming  a  cauliflower-like  mass  of  bleeding  granulations 
(fungus  haematodes) . 

The  consistence  of  the  tumor  varies  greatly;  often  nodulations  alternating 
with  areas  of  softening  are  felt  throughout  its  substance;  it  may  exhibit  parenchy- 
matous hemorrhages  or  various  degenerations,  as  mucoid  or  colloid. 

In  the  early  stages  the  epididymis  may  often  be  felt  entirely  uninvolved. 
Later  it  becomes  infiltrated  and  indistinguishable  from  the  mass  of  the  tumor. 
Hydrocele  or  hsematocele  may  complicate  the  affection  from  the  beginning  and 
conceal  the  enlargement. 

The  swelling  often  develops  without  pain,  though  rarely  when  the  growth  is 


Areas  of  softening 


Fig.   171. — Carcinoma  (teratoma)   of    the    testicle.     (No.   3249. 
From  the  Museum  of  the  Wistar  Institute.) 

very  rapid;  testicular  sensation  is  lost  early.  The  first  symptom  of  lymphatic 
involvement  may  be  pains  referred  to  the  inguinal  region  or  the  back,  or  along 
the  course  of  the  sciatic  nerve,  or  radiating  down  the  thighs.  The  enlarged  ret- 
roperitoneal nodes  may  cause  oedema  of  the  legs  by  pressure  on  the  veins.  They 
can  often  be  felt  through  the  abdominal  wall.  The  inguinal  nodes  are  not  en- 
larged until  the  scrotum  becomes  involved.  Cachexia  becomes  marked  when 
secondary  deposits  develop.  The  vessels  of  the  cord  become  very  large,  thus 
differing  from  the  swelling  caused  by  simple  hydrocele.  Moreover,  the  scrotal 
veins  are  nearly  always  dilated. 

O'Crowley  and  Martland  (personal  communication;   see  also  Transactions 
22. 


338 


GENITO-URINARY  SURGERY 


of  the  American  Urological  Association,  1917)  consider  "that  for  all  practical 
purposes  there  is  but  one  tumor  of  the  testicle,  namely,  a  teratoma,  and  the  most 
common  neoplasm  is  the  alveolar  carcinoma  with  lymphoid  stroma;  the  vast 
number  of  the  varieties  of  testicular  tumors  which  have  been  described  is  due  to 
incomplete  examination — if  the  whole  mass  be  examined,  serial  sections  being 
necessary  in  some  instances,  every  case  will  be  found  to  be  teratomatous. 

"  The  tumor  metastasizes  as  carcinoma,  the  retroperitoneal  lymph-nodes 
being  involved  in  the  vast  majority  of  cases. 


Epididymis 


Cystomatous  area 


Area  in  glandular 
part  of  organ  in 
state  of  carcinoma- 
tous degeneration 


Fig. 


172, — Cystoma    (teratoma)    of  the   testicle.     (No.  3246. 
From  the    Museum  of  the  Wistar  Institute.) 


"  The  growth  is  to  be  differentiated  from  tuberculosis  and  gumma  of  the 
testicle." 

From  a  histological  standpoint,  teratomata  contain  tissue  derived  from  two 
or  three  of  the  primitive  germinal  layers.  In  most  cases  one  of  these  predomi- 
nates, so  that  unless  the  whole  tumor  be  carefully  examined  there  is  danger  of  not 
appreciating  its  mixed  character.  In  the  majority  of  cases  the  great  mass  of 
the  growth  is  composed  of  carcinomatous  tissue  with  lymphoid  stroma.  Islands 
of  cartilage  are  found  in  many  tumors;  muscle  is  less  often  seen;  thyroid  tissue 
is  a  fairly  frequent  finding. 

Diagnosis. — An  apparently  causeless  induration  of  the  testicle,  followed  by 
rapid  and  progressive  increase  in  size  with  little  alteration  in  form,  is  indic- 
ative of  malignant  growth  if  tuberculosis  and  syphilis  be  excluded;   and,  as. 


SURGERY  OF  THE  TESTICLES 


339 


already  indicated,  for  practical  purposes  a  malignant  growth  of  the  testicle  is 
a  teratoma.  Marked  dilatation  of  the  blood-vessels  of  the  cord  and  scrotum 
is  highly  characteristic.  When  the  tumor  is  masked  by  hydrocele,  the  latter 
should  be  treated  by  open  incision,  thus  allowing  the  testis  to  be  inspected  and 
palpated. 

Malignant  growth  following  traumatism  may  be  distinguished  from  traumatic 
orchitis  only  by  the  progressive  increase  in  the  size  of  the  testis.  When  the 
teratoma  is  thoroughly  developed  it  is  not  likely  to  be  confounded  with  any 
other  affection  (Fig.  173).  The  large  tumor,  the  infiltration  of  the  cord,  the 
involvement  of  lymphatic  nodes,  the  discoloration  of  the  scrotum,  the  enlarge- 
ment of  the  blood-vessels,  and  finally  the  cachexia,  are  all  characteristic.     Gum- 


FlG.  173. — Cancer  (teratoma)  of  the  right  testicle.     (Monod  and  Terrilion.) 

ma  of  the  testicle  never  grows  larger  than  the  size  of  the  fist,  and  does  not  en- 
large the  nodes.  Moreover,  it  is  sometimes  bilateral,  the  patient's  blood  gives 
a  positive  Wassermann  reaction,  and  the  tumor  yields  to  specific  treatment. 

Haematocele  may  be  mistaken  for  malignant  disease.  There  should,  how- 
ever, be  a  history  either  of  trauma  with  a  growth  developing  within  a  few  hours, 
or  of  an  old  hydrocele  into  which  hemorrhage  may  have  occurred.  In  heematocele 
pain  is  an  early  symptom,  and  the  swelling  increases  intermittently  and  not 
by  steady  growth;  it  is  less  bossed  and  irregular  than  is  malignant  disease; 
testicular  sensation  is  not  so  completely  lost.  Tapping  may  establish  a  diag- 
nosis, though  it  must  be  remembered  that  there  is  often  blood  effusion  into  the 
tunica  vaginahs  in  cases  of  malignant  disease. 

An  old  hydrocele  with  thickened  sac,  containing  fibro-cartilaginous  material, 


340  GENITO-URINARY  SURGERY 

and  exhibiting  a  hard  and  uneven  surface,  may  resemble  the  hard  form  of  the 
malignant  disease.  When  it  is  impossible  to  distinguish  between  these  two 
affections,  an  early  incision,  followed  by  an  operation  appropriate  to  the  condi- 
tion found,  is  advisable. 

Prognosis. — The  prognosis  of  teratoma  of  the  testicle  is  bad,  particularly 
when  the  retroperitoneal  nodes  are  involved.  Paget  states  that  the  duration 
of  life  is,  on  an  average,  twenty-three  months,  patients  living  about  six  months 
after  operation  since,  as  a  rule,  they  do  not  consent  to  surgical  intervention  until 
they  have  suffered  from  the  disease  for  one  and  a  half  years.  Death  is  nearly 
always  due  to  metastasis.  The  scirrhous  form  of  the  disease  runs  a  slow  course: 
Nepveu  reports  one  case  which  survived  fifteen  years. 

A  few  cases  of  radical  cure  have  been  recorded.  Winiwarter,  among  twelve 
cases,  found  one  living  two  years  and  seven  months  after  operation.  Robin 
and  Volkmann  report  four  cases  as  living  three  years.  Kocher  publishes  the 
records  of  six  cases;  two  were  well  one  year  after  operation,  one  one  and  a  half 
years,  one  four  and  a  half  years,  one  eight  and  a  half  years,  one  ten  and  a  half 
years;  in  only  one  instance  was- the  operation  performed  early. 

Treatment. — Orchidectomy,  with  removal  of  the  cord  up  as  far  as  the 
internal  ring,  the  customary  operation  for  the  condition,  has  an  ultimate  mortality 
of  almost  100  per  cent.  A  more  extensive  operation,  consisting  of,  in  addition, 
incision  of  the  abdominal  wall  down  to  the  peritoneum  from  the  internal  ring 
upward  to  the  costal  margin,  and  stripping  forward  the  serous  rriembrane  till 
the  aorta  and  cava  are  exposed,  so  that  the  retroperitoneal  lymphatic  tissue  may 
be  removed,  seems  to  promise  better  results.  The  testicular  tumor  should  be 
removed,  incised,  and  'examined  before  proceeding  with  the  last  stage  of  the 
operation. 

Castration  or  Orchide^ctomy 

Castration  is  attended  with  little  danger.  Preliminary  cleansing  of  the  opera- 
tive region  should  be  repeated  several  times,  at  intervals  of  some  hours,  and  im- 
mediately before  operation  the  penis  should  be  tightly  bandaged  in  sterile  gauze, 
since  it  is  a  frequent  source  of  infection  in  operations  about  the  genitalia. 

The  incision  varies  in  accordance  with  the  conditions.  When  the  tumor  is 
small  and  non-adherent  and  the  cord  is  not  involved,  an  opening  over  the  ex- 
ternal abdominal  ring  large  enough  to  allow  the  tumor  to  be  pulled  out  suffices. 
If  the  growth  is  large,  adherent,  and  extending  up  the  cord,  the  incision 
should  be  continued  parallel  with  Poupart's  Hgament,  half  an  inch  above  it, 
to  the  position  of  the  internal  ring  or  beyond  this.  Diseased  tissue  should  be 
avoided  in  making  the  dissection,  the  vaginal  tunic  and  the  greater  part  of  the 
scrotal  tissues  of  the  affected  side  being  taken  with  the  growth. 

It  is  advisable  to  remove  as  much  as  possible  of  the  cord  when  any  portion 
of  this  structure  is  involved  in  the  malignant  process,  splitting  the  aponeurosis  of 
the  external  oblique  to  expose  the  portion  in  the  inguinal  canal.  When  there 
is  need  for  haste  it  may  be  transfixed  with  a  gut  suture,  tied  in  two  portions,  and 
divided,  the  stump  of  the  vas  being  cauterized  with  phenol.  It  is  a  little  safer, 
however,  to  cut  through  the  cremaster  and  secure  the  spermatic,  cremasteric, 
and  deferential  arteries  separately;  the  veins  may  be  tied  in  one  or  two  masses. 
The  deferential  artery  is  found  close  to  the  vas,  and  with  it  are  a  few  veins; 
the  cremasteric  lies  to  the  outer  side  of  the  cord,  near  its  surface;  the  spermatic 


SURGERY  OF  THE  TESTICLES 


341 


is  in  front  of  the  cord,  surrounded  by  the  anterior  group  of  veins,  and  can 
scarcely  be  distinguished  from  them.  The  divided  cord  should  be  secured  with 
artery  forceps  until  the  end  of  the  operation.  The  bleeding  from  the  scrotal  tissues 
is  controlled  by  forcipressure  or  ligatures,  and  redundant  portions  of  the  scrotum, 
particularly  those  which  may  be  infiltrated,  are  removed.  The  edges  of  the 
wound  are  then  approximated,  care  being  taken  to  prevent  inversion  by  the 
dartos.  The  sutures  should  be  of  silk;  the  last  one  may  secure  a  drainage-tube 
in  the  lower  angle  of  the  wound  if  the  case  has  been  an  infected  one.  Other- 
wise drainage  is  unnecessary. 

An  aseptic  dressing  is  applied  and  held  in  place  by  the  crossed  bandage  of 
the  perineum. 

The  patient  may  sometimes,  complain  of  retention  of  urine,  lasting  from 
twenty-four  to  thirty-six  hours.  This  is  best  relieved  by  enemata  of  hot  saline 
solution.  Should  this  fail,  the  catheter  may  be  used.  The  stitches  are  removed 
on  the  fifth  to  the  seventh  day. 


Fig.  174. — Intravaginal  spermatocele.    (Hochenegg.) 

Cysts,  or  Encysted  Hydrocele,  of  the  Epididymis  and  Testis. — In 
this  affection  the  fluid  is  contained  in  distinct  cysts,  which  may  or  may 
not  project  into  the  cavity  of  the  vaginal  tunic;  this  tunic,  or  at  least  its 
parietal  layer,  does  not  form  the  walls  of  the  cysts.  These  cysts  may 
originate  in  the  epididymis,  in  foetal  structures  lying  near  by,  or  in  the 
testicle  (Fig.  174).  They  may  contain  a  milky  fluid,  which  under  the 
microscope  is  found  to  be  filled  with  spermatozoa  (this  is  particularly  true 
of  the  larger  cysts),  or  their  contents  may  be  perfectly  translucent,  but  differing 
markedly  from  hydrocele  in  composition,  since  they  contain  little  or  no  al- 
bumen. 

Cysts  of  the  Epididymis. — These  cysts  may  be  small  or  large;  the  small 
cysts  are  usually  multiple,  and,  according  to  Gosselin,  develop  in  the  majority  of 
testes  after  middle  life.  They  may  be  very  minute  or  are  large  as  a  pea,  and  are 
sometimes  pedunculated.  They  are  easily  shelled  out  from  the  surrounding 
tissue.  Exceptionally  they  contain  spermatozoa.  They  are  placed  both  on  the 
surface  and  in  the  parenchyma  of  the  epididymis.     While  they  may  develop 


342 


GENITO-URINARY  SURGERY 


from  the  remnants  of  foetal  structure,  it  seems  more  probable  that  they  are 
involution  cysts,  originating  in  the  tissue  of  the  epididymis,  but  becoming  sub- 
serous. 

The  large  cysts  are  parenchymatous,  arising  beneath  the  outer  covering 
of  the  epididymis  and  close  to  its  upper  part,  or  between  it  and  the  upper 
part  of  the  testicle  (Fig.  175).  They  lie  outside  of  the  visceral  layer  of  the 
vaginal  tunic,  pushing  this  upward  as  they  become  distended,  and  are  in  close 
contact  with  the  seminal  ducts.  They  are  usually  single,  but  may  be  multiple 
or  multilocular.    Commonly  the  fluid  is  milky  from  the  spermatozoa  which  it 


T... 


Fig.  175. — Encysted  hydrocele  (large 

cysts). 


Fig.  176. — Multilocular  cyst  of  the  epididy- 
mis. T,  testicle;  E.  epididymis  displaced  by 
the  cyst.     (Monod  and  Terrillon.) 


contains,  though  it  may  be  limpid.  These  cysts  may  arise  from  retention 
cysts  or  from  the  development  of  the  foetal  remains.  Spermatozoa  may  find 
their  entrance  into  them  through  minute  openings,  difficult  to  recognize  at  any 
time,  and  capable  of  closing  before  the  cyst  is  examined.  They  rarely  at- 
tain great  dimensions,  containing  on  an  average  not  more  than  two  or  three 
ounces  of  fluid.  Exceptionally  they  may  form  large  tumors  (Fig.  176).  They 
are  not  confined  to  old  age,  developing  at  any  time  after  full  sexual  maturity. 

Morris  states  that  the  cyst  may  originate  as  a  retention  cyst  due  to  dilata- 
tion of  a  seminal  tube,  owing  to  some  obstruction  in  the  vas  deferens  or  other 


SURGERY  OF  THE  TESTICLES  343 

part  of  the  excretory  passages  (Liston,  Luschka,  and  others) ;  or  as  a  new 
formation  in  the  connective  tissue  between  the  tubes  of  the  epididymis  sub- 
sequent upon  the  rupture  of  a  seminal  tubule  and  the  escape  of  some  drops  of 
seminal  fluid.  The  opening  in  the  duct  may  afterwards  cicatrize,  so  that  there 
need  not  persist  a  communication  between  the  duct  and  the  new-formed  cyst. 

The  cyst  may  be  formed  originally  in  the  connective  tissue,  and  by  gradua- 
ally  enlarging  may  cause  subsequently  the  rupture  of  a  seminal  tubule,  and 
thus  the  entrance  into  the  cyst  of  spermatozoa  (CurUng). 

The  foetal  structures  from  which  cysts  of  the  epididymis  originate  are — 

(1)  The  paradidymis,  or  organ  of  Giraldes,  a  minute  body,  the  remnant  of 
the  mesonephros  or  glandular  portion  of  the  Wolffian  body.  This  is  situated 
in  front  of  the  lower  part  of  the  vas  and  above  the  head  of  the  epididymis 
and  behind  the  upper  part  of  the  tunica  vaginalis.  Cysts  having  this  origin 
are  situated  above  the  testis  and  epididymis,  and  extend  sometimes  a  little 
way  along  the  cord.     They  correspond  to  paroophoritic  cysts  in  the  female. 

(2)  The  ducts  of  Kobelt,  which  are  remnants  of  the  tubules  of  the  Wolffian 
body,  situated  in  the  globus  major.  (3)  The  vestiges  of  the  duct  of  Miiller, 
part  of  which  is  represented  by  the  hydatid  of  Morgagni,  can  sometimes  be 
traced  from  the  globus  major  down  to  the  globus  minor,  along  the  body  of 
the  epididymis  in  the  digital  pouch.  Cysts  derived  from  these  sources  are 
situated  between  the  epididymis  and  testis,  most  frequently  between  the  globus 
major  and  the  upper  end  of  the  testis.  Those  derived  from  the  vasa  efferentia 
and  other  remnants  of  the  Wolffian  tubules  are  homologous  with  parovarian 
cysts  in  the  female.  (4)  The  vas  aberrans  of  Haller,  which  is  a  diverticulum 
of,  or  a  convoluted  caecal  tube  opening  into,  the  vas  deferens  close  to  the  lower 
end  of  the  epididymis;  this  also  is  a  part  of  the  remains  of  one  of  the  tubes 
of  the  Wolffian  body  still  in  connection  with  the  representative  of  the  excretory 
duct  of  that  body, — namely,  the  vas  deferens. 

Cysts  of  the  Testis. — These  grow  in  front  of  the  gland  between  the  tunica 
albuginea  of  the  testis  and  the  testicular  portion  of  the  tunica  vaginalis.  They 
are  usually  of  small  size,  and  from  intracystic  tension  feel  like  a  hard  body. 

Symptoms  of  cysts  of  the  epididymis  and  testis  are  slow  in  developing, 
though  exceptionally,  from  traumatic  rupture  of  a  cyst  into  the  cavity  of  the 
vaginal  tunic,  there  may  be  swelling  and  pain  characteristic  of  acute  hydrocele. 
Small  cysts,  particularly  those  of  the  epididymis,  are  recognized  with  difficulty 
even  by  careful  palpation.  As  they  increase  in  size  they  form  distinct  fluctu- 
ating tumors,  which,  if  the  fluid  is  clear,  transmit  light.  These  cysts  have  often 
been  mistaken  for  supernumerary  testicles,  or,  because  of  tension  and  consequent 
hardness,  for  tuberculous  infiltration  of  the  epididymis.  They  seldom  reach 
large  size. 

Diagnosis  is  founded  upon  translucency  when  the  fluid  contained  in  the  cyst 
is  limpid.  Thrill,  fluctuation,  want  of  density  and  resistance,  and  slowness  in 
development  distinguish  these  cysts  from  sarcoceles.  In  shape  they  are  globular 
when  small,  but  if  large  and  multilocular  the  shape  varies  greatly.  By  trans- 
mitted light  the  testicle  is  usually  seen  lying  below  and  in  front  of  the  tumor, 
although  it  may  be  to  one  or  the  other  side,  more  frequently  the  inner.  On  pal- 
pation it  is  often  possible  to  determine  that  the  enlargement  is  absolutely  limited 


344  GENITO-URINARY  SURGERY 

to  the  upper  portion  of  the  testis  and  epididymis,  and  has  a  tendency  to  extend 
upward  along  the  cord,  the  testis  proper  being  perfectly  normal  and  the  tunica 
vaginalis  containing  no  fluid.  At  times  exploratory  puncture  with  a  hypodermic 
needle  will  be  necessary  before  a  diagnosis  can  be  established.  The  fluid  ob- 
tained will  generally  be  found  swarming  with  spermatozoa. 

Treatment. — These  cysts  grow  so  slowly  and  cause  so  few  symptoms  that 
intervention  is  often  not  necessary.  Evacuation  by  means  of  an  aspirator  or  a 
small  trocar  and  cannula  may  be  followed  by  cure.  If  this  fails,  the  scrotum 
may  be  opened  and  the  cyst  dissected  out.  The  operation  of  excision  is  particu- 
larly indicated  when  the  cysts  are  multiple  or  multilocular.  When  complete 
excision  is  impossible  without  extensively  injuring  the  structure  of  the  testis  oi 
epididymis,  the  cyst-wall  should  be  removed  as  thoroughly  as  possible,  and  the 
remaining  portion  should  be  cauterized  with  carbolic  acid. 

HYDROCELE 

"  Hydrocele  "  indicates  an  abnormal  amount  of  fluid  about  the  testis  or  the 
cord,  limited  by  the  tunica  vaginalis;  without  further  qualifying  words,  as  "  en- 
cysted "  or  "  of  the  cord,"  a  serous  effusion  between  the  two  layers  of  the  tunica 
vaginalis  testis  is  implied. 

Prolongations  of  peritoneum,  called  the  vaginal  processes,  precede  the  testi- 
cles in  their  descent  into  the  scrotum,  thus  forming  a  pouch,  into  which  the 
testicle  with  its  epididymis  is  invaginated.  The  funicular  portion  of  this  pouch 
usually  becomes  obliterated  from  the  internal  abdominal  ring  to  a  point  just 
above  the  testis,  leaving  a  serous  sac  enveloping  this  organ,  in  which  is  normally 
found  just  enough  fluid  to  allow  its  surfaces  to  glide  smoothly  over  each  other. 

The  invagination  of  the  testicle  into  the  peritoneal  pouch  necessarily  forms 
a  parietal  and  a  visceral  portion.  The  parietal  portion  forms  a  loose  invest- 
ment, extending  above  and  below  the  testis,  and  connected  by  cellular  tissue 
to  the  surrounding  structures  of  the  scrotum.  The  visceral  portion  invests  the 
testis  and  the  epididymis,  connecting  these  structures,  and  forming  a  fossa 
or  pouch  between  them  (digital  fossa).  At  the  posterior  portion  of  the  gland 
it  becomes  continuous  with  the  parietal  layer.  The  tail  and  body  of  the  epididy- 
mis are  not  included  in  the  double  serous  envelope,  since  the  reflection  of  the 
visceral  layer  is  upon  the  front  and  sides  of  the  scrotal  ligament  of  the  testicle, 
a  fibro-muscular  band  passing  from  the  lower  posterior  portion  of  the  testis  and 
the  body  of  the  epididymis  to  the  dartos. 

ACUTE  HYDROCELE 

This  affection,  an  acute  vaginalitis,  is  usually  due  to  extension  of  acute 
inflammation  from  the  epididymis.  It  may  also  be  secondary  to  orchitis,  and 
may  be  caused  by  traumatism. 

It  is  probable  that  in  every  case  of  epididymitis  there  is  some  extension  of 
inflammation  to  the  tunica  vaginalis,  and  that  the  acute  effusions  which  com- 
plicate infectious  disease  or  catheter  urethritis  are  secondary  to  epididymitis  or 
orchitis. 

The  pathological  changes  in  the  tunica  vaginalis  are  essentially  the  same  as 


SURGERY  OF  THE  TESTICLES  345 

those  occurring  in  acute  inflammation  of  serous  membranes  in  other  parts  of 
the  body. 

The  effusion  may  be  serous  or  fibrinous.  Serous  effusion,  though  common, 
is  not  ofterf  examined  clinically,  since  it  is  sHght,  transitory^  and  indicative  of 
a  mild  inflammation.  Plastic  effusion  does  not  differ  from  ordinary  inflamma- 
tory lymph.    Suppuration  is  extremely  rare. 

Symptoms. — The  symptoms  of  acute  hydrocele  are  masked  by  those  of  the 
primary  disease.  .  Thus,  in  gonorrhceal  epididymitis  the  usually  moderate  amount 
of  effusion  into  the  vaginal  tunic  is  obscured  by  the  oedematous  swelling  of  the 
entire  scrotum.  If  effusion  is  abundant  it  will  form  a  tense,  rounded  or  pyriform, 
fluctuating  tumor  which  is  translucent  and  which  feels  like  a  greatly  enlarged 
testicle. 

The  pain  attending  acute  hydrocele  is  sometimes  extremely  severe,  corre- 
sponding in  type  precisely  to  that  of  gonorrhceal  epididymitis.  This  pain  is 
doubtless  due  to  tension,  since  puncture  affords  almost  immediate  relief.  In 
addition  to  pain  and  swelling  there  are  present  heat,  redness,  and  scrotal  oedema. 
The  general  constitutional  symptoms  are,  as  a  rule,  slight. 

Diagnosis. — The  most  important  single  diagnostic  sign  is  translucency. 
This  symptom  is  best  elicited  by  looking  through  a  tube  not  more  than  half  an 
inch  in  diameter  held  against  the  scrotum  toward  a  not  too  intense  light  held 
on  the  opposite  side  of  the  tumor.  The  test  is  most  delicate  when  but  a  small 
area  of  the  skin  is  illuminated.  It  may  be  performed  with  great  satisfaction  with 
the  aid  of  two  urethroscopic  tubes,  one  of  which  is  used  to  illuminate  a  small 
spot  by  pressing  its  end  against  the  scrotal  skin,  while  the  second  is  used  as  a 
speculum.  If  the  examination  is  performed  in  a  darkened  room  and  the  light 
is  guarded  as  suggested,  frequently  the  examination  tube  may  be  dispensed  with. 

On  the  subsidence  of  acute  inflammation  the  diagnosis  can  be  made  without 
difficulty  by  determining  the  presence  of  fluid.  This  test  is  made  by  seizing  the 
scrotum  in  the  left  hand  and  making  the  skin  over  the  swelling  moderately 
tense.  Then,  by  sudden  pressure  with  the  finger  of  the  right  hand,  the  sensa- 
tion of  liquid  being  pressed  aside  will  be  noted  before  the  comparatively  firm 
resistance  of  the  testicle  is  felt;  or  by  the  alternate  pressure  of  the  two  hands 
fluctuation  may  be  detected.  When  inflammation  has  still  further  subsided,  the 
presence  or  absence  of  fibrinous  deposits  may  be  determined  by  seizing  the 
testicle  in  front  and  pressing  it  backward  from  between  the  thumb  and  fingers. 
Ordinarily  it  readily  slips  back,  leaving  in  the  grasp  the  scrotal  tissue  and  the 
external  layer  of  the  vaginal  tunic.  If  the  parietal  and  visceral  layers  of  the 
vaginal  tunic  are  adherent,  the  testicle  wull  not  slip  back  from  the  grasp  in  this 
way,  or,  if  it  does,  will  leave  a  thickened  mass  between  the  thumb  and  fingers. 

Examination  of  the  subsidence  of  inflammation  will  generally  show  thick- 
ening and  induration  of  the  epididymis. 

Prognosis. — Acute  hydrocele  undergoes,  usually,  resolution;  the  plastic  de- 
posit may  organize  partially  or  completely,  obliterating  the  cavity  of  the  tunica 
vaginalis;  the  inflammation  may  become  chronic,  constituting  the  ordinary  form 
of  hydrocele,  and  in  this  case  organization  of  the  fibrinous  tissue  often  divides 
the  general  cavity  into  secondary  ones,  distinctly  separated  from  one  another; 
or,  finally,  suppuration  may  take  place. 


346 


GENITO-URINARY  SURGERY 


{a)Hydrocele  of  Tunica 
Vaginalis.  —  The 
fluid  is  in  a  sac  con- 
nected with  that  of 
the  tunica  vaginaHs. 


Encysted  Hydrocele. 
— The  fluid  is  in  a 
sac  distinct  from 
that  of  the  tunica 
vaginahs. 


Treatment. — This  is  essentially  that  of  the  underlying  condition,  and  there- 
fore includes  rest  to  the  part,  elevation,  and  evaporating  lotions  or  counter- 
irritants.  Pelvic  congestion  is  to  be  avoided  by  regular  and  free  evacuation  of  the 
bowel.  If  pain  be  a  prominent  symptom,  aspiration  should  be  promptly  per- 
formed. In  the  latter  stages  the  application  of  a  pressure  suspensory  appears 
to  be  of  advantage. 

If  the  effusion  is  not  absorbed  in  six  weeks,  treatment  appropriate  to  chronic 
hydrocele  is  undertaken. 

CHRONIC  HYDROCELE 

Jacobson  thus  classifies  chronic  hydrocele: 

1.  Ordinary  Hydrocele. — The  fluid  distends 
the  closed  sac  of  the  tunica  vaginalis. 

2.  Congenital  Hydrocele. — A  communication 
exists  between  the  cavity  of  the  tunica 
vaginalis    and    that    of    the   peritoneum. 

3.  Infantile  Hydrocele. — The  tunica  vaginalis 
and  the  funicular  process  are  distended 
with  fluid,  but  these  are  shut  off  from 
the  peritoneal  cavity  by  an  obliteration 
placed  usually  at  the  external  ring. 

4.  Inguinal  Hydrocele.— Hydrocele  in  relation 
with  a  retained  testis. 

f     1.  Encysted  Hydrocele  of  the  Epididymis. — 
(;8)    Encysted  Hydrocele.  '.  The  fluid  is  encysted   in  the  neighbor- 

-   ■  -    -     •  hood  of  the  epididymis. 

{     2.  Encysted   Hydrocele    of   the    Testis. — The 

fluid    is    encysted    between    the    tunica 

albuginea  and  the  inner  surface  of  the 

'[  tunica   vaginalis. 

(a)  Diffused. — The  fluid  forms  a  serous  collection  of  the  nature  of  oedema 

in  the  cellular  tissue  of  the  cord. 
(/3)   Encysted. — The  fluid  is   contained  in   a   distinct  sac  originating  usually 

(1)  in   some   unobliterated   part   of   the   processus    f  uniculo-vaginalis ; 

(2)  in  a  cyst  formed  independently  of  this  process, — e.g.,  by  dilatation 
of  persistent  tubules  of  the  organ  of  Giraldes. 

(a)  With  other  Coexisting  Hydroceles. — E.g.,  (1)  hydrocele  of  the  tunica 
vaginalis  with  encysted  hydrocele  of  the  testis;  (2)  hydrocele  of  the 
tunica  vaginalis  with  encysted  hydrocele  of  the  cord.;  (3)  hydrocele 
of  the  tunica  vaginalis  with  diffused  hydrocele  of  the  cord. 

(B)  With  Hernia. — E.g.,  (1)  hydrocele  of  the  tunica  vaginalis  with  inguinal 
hernia;   (2)  hydrocele  of  the  cord  with  inguinal  hernia. 

IV.  Hydrocele  of  the  sac  of  a  hernia. 


O 


[^ 


HYDROCELE  OF  THE  TUNICA  VAGINALIS  TESTIS 

(Fig.  177.)  This,  the  ordinary  form  of  hydrocele,  and  most  common  in 
infancy  and  old  age,  is  in  the  majority  of  cases  secondary  to  pathological  condi- 
tions of  the  epididymis,  testicle,  or  cord.  It  is  particularly  associated  with  dis- 
ease of  the  epididymis. 

Loose  cartilaginous  bodies  are  sometimes,  but  rarely,  found  within  the  sac, 
and  may  by  their  continued  irritation  give  rise  to  an  abnormal  secretion  of 
fluid.  Hydrocele  may  be  due  to  passive  exudation  caused  by  an  obstruction 
to  the  return  of  circulation.  This  exudation  may  be  caused  by  an  ill-fitting 
truss,  by  the  presence  of  filarise,  or  by  hepatic  or  renal  disease.  The  frequent 
occurrence  of  hydrocele  in  warm  climates  and  in  persons  suffering  from  malaria 


SURGERY  OF  THE  TESTICLES 


347 


is  due  to  associated  hepatic  enlargements.  In  general  dropsy  the  scrotal  tissues 
may  be  cedematous,  but  fluid  in  the  tunica  vaginalis  is  seldom  or  never  found. 

A  certain  number  of  cases  seem  to  be  idiopathic — i.e.,  there  is  no  discovera- 
ble preceding  inflammation  of  the  scrotal  contents. 

Chronic  hydrocele  may  begin  in  the  acute  form,  the  effusion  failing  to  be 
absorbed,  and  gradually  increasing  in  quantity,  or  the  onset  may  be  insidious, 
the  patient  first  detecting  the  condition  by  the  increase  in  the  size  of  the  scrotum. 

Jacobson  holds  that  "  in  the  great  majority  of  cases  the  effusion  of  fluid 
commences  passively,  and  v^^ithout  any  irritation  or  inflammation  to  begin  with, 
the  causes  predisposing  to  its  production  being  the  pendent  position,  the  less 


Fig.  177. — Vertical  section  of  hydrocele.     (Kocher.) 

vigorous  condition  of  the  cremaster  and  dartos,  feebler  cardiac  circulation,  de- 
ficiency of  tone  in  the  scrotal  blood-vessels  and  lymphatics,  together  with, 
perhaps,  a  tendency  to  venous  congestion  from  hepatic  and  renal  degeneration. 

It  is  evident  that  from  the  etiological  standpoint  hydroceles  may  be  classed 
as  those  developing  primarily,  and  those  secondary  to  traumatism,  inflammation, 
or  degeneration  .of  the  testicle,  epididymis,  or  cord. 

The  fluid  of  chronic  hydrocele  is  clear,  yellowish,  and  much  like  that  found 
in  ascites.  The  specific  gra\aty  is  about  1022,  the  reaction  is  neutral  or  slightly 
alkaline,  and  the  fluid  contains  fibrin,  albumin,  and  paraglobulin.  The  quantity 
of  albumin  (from  four  to  six  per  cent.)  found  in  the  fluid  strongly  suggests  the 
inflammatory  origin  of  the  affection. 


348 


GENITO-URINARY  SURGERY 


In  some  cases  cholesterin  crystals  are  seen  in  the  contents  of  a  hydrocele, 
giving  it  a  beautiful  shimmering  appearance.  There  is  sometimes  slight  ad- 
mixture of  blood,  the  coloring-matter  of  which  may  be  deposited  in  the  form 
of  blackish  sediment.    Tubercle  bacilli  have  been  found. 

The  average  amount  of  fluid  is  from  four  to  eight  ounces.  This  produces 
a  tumor  of  such  dimensions  that  it  becomes  inconvenient,  and  the  patient  seeks 
surgical  help.  Some  extraordinarily  large  accumulations  have  been  observed, 
in  one  case  more  than  six  gallons. 

Symptoms. — Chronic  hydrocele,  unlike  the  acute  affection,  is  "characterized 
by  the  absence  of  symptoms,  the  patient  experiencing  no  inconvenience  aside 


■i$i. 


Fig.  178.— Hydrocele. 

from  the  weight  and  size  of  the  tumor.  The  rate  of  growth  varies  greatly.  It 
may  reach  a  large  size  in  a  few  weeks,  or  may  increase  so  slowly  that  a  tumor 
of  troublesome  dimensions  is  not  formed  for  years. 

The  tumor  is  usually  smooth,  tense,  fluctuating,  and  pyriform,  with  the  base 
below.  It  begins  at  the  lower  portion  of  the  scrotum  and  grows  upward.  The 
veins  of  the  scrotum  and  cord  are  not  dilated  in  proportion  to  the  size  of  the 
growth.  The  cord  can  usually  be  felt  at  the  apex  of  the  tumor;  testicular  pain, 
when  elicited,  gives  information  as  to  the  position  of  this  organ.  The  skin  is 
smooth,  and  apparently  normal.  If  the  tumor  is  held  in  one  hand  and  lightly 
percussed  with  one  finger  of  the  other,  a  vibrating  thrill  is  felt  which  is  char- 


SURGERY  OF  THE  TESTICLES 


349 


acteristic  of  fluctuation.  When  the  sweUing  reaches  large  dimensions  the  penis 
is  practically  concealed  in  a  fold  of  the  skin.  The  tumor  is  dull  on  percussion, 
is  heavy,  and  when  pushed  back  between  the  legs  springs  forward  again  to  its 
original  position  (Fig.  178). 

Coincidently  with  the  accumulation  of  fluid  there  is  often  chronic  thickening 
of  the  vaginal  tunic;  this  exceptionally  undergoes  cartilaginous  or  calcareous 
degeneration.  Sometimes  the  visceral  and  parietal  walls  of  the  tunica  vaginalis 
become  adherent  at  points.  Under  these  circumstances  palpation  may  show 
certain  indurated  spots  or  distinct  lobules. 

It  is  important  to  know  the  position  of  the  testicle  in  hydrocele,  since  other- 
wise it  may  be  wounded  in  operations  designed  for  cure.  This  gland  usually 
lies  in  the  mid-posterior  portion  of  the  tumor.  Exceptionally,  when  there  is  in- 
version or  when  adhesions  have  formed,  the  testicle  lies  directly  in  front  of  the 
tumor  and  may  be  readily  wounded,  or  it  may  lie  at  its  lower  pole  (Fig.  179). 
The  position  of  the  testicle  is  determined  by  pressure.    This,  if  suddenly  exerted 


Fig.  179. — Vertical  section  of  a 
hydrocele,  showing  the  testicle  lying 
below  the  cyst.      (Kocher.) 


Fig.  180. — Inguinal 
hernia  with  hydrocele. 
(Kocher.) 


by  one  or  two  fingers  over  various  parts  of  the  tumor,  will  produce  the  char- 
acteristic sickening  pain  when  the  testicle  is  reached.  Transmitted  light  vdll 
better  show  the  position  of  the  testicle. 

Diagnosis. — The  diagnosis  is  based  upon  the  development  of  a  tumor  in  the 
lower  part  of  the  scrottmi,  its  fluctuation,  its  pyriform  shape,  its  projection 
forward,  its  translucency,  and  the  small  size  of  the  cord.  The  Hght  test  should 
be  conducted  as  described  under  acute  hydrocele.  This  test  -vvill  fail  when  the 
hydrocele  contains  a  large  quantity  of  cholesterin  or  when  the  fluid  is  turbid 
from  blood,  fat.  or  spermatozoa.  Omental  hernia  may  be  slightly  translucent, 
but  the  bright  red  glow  so  characteristic  of  ordinar\^  hydrocele  is  never  seen. 
WTien  the  fluctuation,  transparency,  and  testicular  sensation  cannot  be  elicited, 
the  diagnosis  vrill  depend  upon  the  use  of  an  aspirating  needle,  or,  better  than 
this,  an  incision,  since  thus  can  be  made  a  thorough  examination  of  both  the 
testicle  and  the  epididymis. 


350  GENITO-URINARY  SURGERY 

The  differential  diagnosis  is  to  be  made  from  hernias,  neoplasms,  other 
varieties  of  hydrocele,  and  haematocele. 

The  diagnosis  from  hernia,  unless  there  exists  incarceration  or  strangulation, 
with  excessive  exudation  and  without  the  typical  abdominal  symptoms,  is  usually 
not  difficult.  In  hernia  there  are  impulse  upon  coughing  and  percussion  reso- 
nance; the  tumor  hangs  directly  down  instead  of  protruding  forward,  grows 
smaller  or  disappears  in  the  night,  is  reduced  with  a  "  flop,"  and  in  its  develop- 
ment is  first  perceptible  in  the  groin,  then  slowly  reaches  the  scrotum;  more- 
over it  can  be  traced  through  its  opening  into  the  abdominal  cavity.  In  none 
of  these  respects  does  it  resemble  hydrocele.  In  the  ordinary  hydrocele  palpation 
shows  that  the  inguinal  canal  is  empty,  fluctuation  is  readily  elicited,  and  trans- 
lucency  is  marked.  These  are  all  characteristics  not  found  in  hernia.  When, 
however,  a  hydrocele  becomes  acutely  inflamed  from  injury  or  other  cause,  and 
when  the  history  of  its  formation  is  uncertain,  diagnosis  may  be  extremely 
difficult,  and  must  be  based  mainly  upon  the  absence  of  abdominal  symptoms. 
Hernia  and  hydrocele  may  coexist;  in  this  case  the  typical  symptoms  of  each 
pathological  condition  may  be  elicited  (Fig.  180). 

From  haematocele  the  m.ore  rapid  growth  of  the  swelling,  the  history  of  an 
injury  or  recent  tapping,  and  the  absence  of  thrill  and  translucency,  will  some- 
times aid  in  the  diagnosis,  but  when  the  tunic  of  the  hydrocele  is  thickened  or 
when  its  contents  are  opaque  diagnosis  is  impossible. 

These  same  conditions  render  the  diagnosis  from  tumor  difficult.  Tumor, 
however,  is  heavier  and  denser  than  hydrocele,  exhibits  marked  dilatation  of 
the  vessels  of  the  cord  and  scrotum,  and  is  attended  by  lymphatic  enlargement 
(lumbar  and  sacral  lymph  nodes).  In  case  of  doubt,  incision  is  indicated,  since 
tumor  in  its  comparatively  early  stages  may  be  concealed  by  an  accompanying 
hydrocele. 

Prognosis. — Spontaneous  cure  is  comparatively  common  in  children.  It 
hardly  ever  takes  place  in  adults.  So  far  as  life  is  concerned,  hydrocele  is  not 
dangerous,  though  it  encourages  the  development  of  hernia,  may  lead  to  testicu- 
lar atrophy,  and  occasionally  suppurates.  As  a  result  of  traumatism  it  may 
rupture  into  the  tissues  of  the  scrotum. 

Treatment 

The  hydrocele  of  infants  usually  seems  to  be  cured  by  the  application  of 
slightly  stimulating  lotions,  such  as  ammonium  muriate  ten  grains  to  the  ounce 
of  water,  or  an  aqueous  solution  of  ichthyol  three  per  cent.  The  efficiency  of 
these  applications  is  questionable,  and  it  is  probable  that  when  the  effusion 
disappears  this  occurs  spontaneously,  practically  uninfluenced  by  the  local  treat- 
ment. Cases  which  resist  treatment  by  local  applications  should  be  tapped  with 
a  needle  of  moderate  size  (20  gauge),  the  removal  of  the  fluid  being  followed 
by  the  injection  of  two  or  three  minims  of  pure  phenol.  A  week  after  such  an 
injection  any  fluid  present  should  be  again  removed. 

The  operative  treatment   m.ay  be  palliative  or   curative. 

Palliative  treatment  consists  in  evacuation  of  the  fluid  contents  of  the 
hydrocele.  In  the  chronic  form  of  the  disease  there  is  almost  reaccumulation, 
but  this  tapping  may  be  repeated  from  time  to  time  as  the  necessity  for  it  is 
indicated  by  full  distention. 


SURGERY  OF  THE  TESTICLES 


351 


The  position  of  the  testicle  is  first  determined  by  means  of  the  light  test 
and  by  palpation,  and  the  presence  of  hernia  is  carefully  excluded.  Excep- 
tionally  the  gut  becomes  invaginated  into  the  sac  of  a  hydrocele,  and  might 
then  readily  be  wounded  by  the  trocar  (Fig.  181).  The  patient  hes  either 
fiat  on  his  back  or  in  a  semi-recumbent  position.  The  skin  of  the  scrotum 
having  been  thoroughly  disinfected,  an  exploratory  puncture  is  made  with  a 
small  hypodermic  needle.  The  site  of  the  proposed  tapping  is  then  infiltrated 
with  novocaine  and  the  skin  punctured  with  tenotome, 
while  the  sac  is  made  tense  by  seizing  it  from  behind 
with  the  left  hand.  The  trocar  is  plunged  into  the 
anterior  part  in  an  upward  and  backward  direction, 
care  being  taken  to  avoid  any  superficial  vein  which 
may  be  apparent;  the  depth  to  which  the  trocar  is 
plunged  should  be  limited  by  keeping  the  thumb-  or 
finger-nail  in  contact  with  the  cannula  (Fig.  182).  By 
observing  this  precaution  and  by  thrusting  the  trocar 
in  the  proper  direction  all  danger  of  wounding  the 
testicle  is  avoided,  if  its  position  has  been  before  deter- 
mined. When  the  sac  has  been  emptied,  the  cannula 
is  immediately  withdrawn  and  the  small  opening  is 
closed  by  a  fragment  of  gauze  held  in  place  by  collodion.  In  performing  this 
operation  it  is  important  to  have  the  trocar  sharp  and  the  cannula  accurately 
fitted  to  it,  as  otherwise  the  sac  will  be  pushed  before  the  point  of  the  instrument 
and  will  not  be  opened.  Practically  the  only  complication  which  can  occur,  save 
septic  infection,  is  wounding  of  either  the  testicle  or  a  large  vein,  with  the 
effusion  of  blood  into  the  hydrocele  sac  or  the  cellular  substance  of  the  scrotum. 
Elevation  and  pressure  applied  by  the  crossed  of  the  perineum  bandage  or  with 


Fig.  181. — Inguinal  tiemia 
invaginating  the  upper  portion 
of  the  sac  of  a  hydrocele 
(Kocher). 


Fig.  182. — Tapping  a  hydrocele. 

a  well-fitting  jock-strap  are  usually  sufficient  to  check  this  bleeding.  After  a 
tapping  there  is  no  need  to  limit  the  patient's  activities  unless  they  be  such  as 
to  imply  violent  muscular  effort. 

Curative  Treatment. — Under  this  heading  are  included  the  various  cutting 
operations,  having  for  their  purpose  the  obliteration  of  the  sac. 

Excision. — Excision  of  the  parietal  layer  of  the  tunica  vaginalis  is  indicated 
when  the  membrane  is  greatly  thickened.  It  is  performed  by  dissecting  this 
tunic  from  the  tissues  of  the  scrotum  and  cutting  it  away. 


352 


GENITO-URINARY  SURGERY 


The  field  of  operation  is  prepared  in  accordance  with  general  surgical  prin- 
ciples. The  sac  is  made  tense  by  an  assistant,  and  under  local  or  general  anaes- 
thesia the  scrotal  covering  is  divided  by  a  vertical  cut  running  from  the  top 
to  the  bottom  of  the  tumor.  After  complete  haemostasis  the  vaginal  tunic 
is  incised  sufficiently  to  admit  a  finger,  and  the  condition  and  position  of  the 
testicle  are  clearly  defined.  The  remainder  of  the  sac  is  then  split  up  with  a 
blunt  pair  of  scissors,  and  the  tunica  vaginalis  is  dissected  from  the  scrotum. 
This  can  usually  be  accomplished  by  sponging  and  an  occasional  push-cut  with 
the  knife.  The  bleeding  points  should  be  picked  up  with  hsemostatic  forceps, 
which  should  be  left  on  until  the  operation  is  completed.  When  the  parietal 
layer  has  been  dissected  free  it  should  be  cut  away  from  the  testicle  and  epi- 
didymis as  closely  as  possible.     Cysts  or  fibrous  bodies  attached  to  the  visceral 


Fig.  183. — First  step  in  operation  for  hy- 
drocele. Scrotal  coverings  incised  down  to 
glistening  wall  of  sac. 


Fig.  184. — Operation  for  hydrocele.     Testicle 
everted  and  redundant  edges  of  sac  being  cut  away. 


portion  of  the  sac  should  be  removed.  The  wound  should  be  closed  without 
drainage  if  haemostasis  be  complete  and  the  skin  suture  accurate,  a  properly 
fitting  jock-strap  over  a  sterile  dressing  will  enable  the  patient  to  resume 
immediately  his  usual  vocation. 

The  external  dressing  should  be  antiseptic  and  compressing  (crossed  of  the 
perineum).     Sutures  are  removed  on  the  third  to  the  fifth  day. 

Eversion  of  the  Sac. — The  most  used  method  consists  in  incising  the  scro- 
tum down  to  the  serous  layer  of  the  sac  for  a  sufficient  distance  to  deliver  the 
cyst,  freeing  it  from  the  surrounding  tissues,  incising  it  along  its  anterior  sur- 
face, and,  finally  suturing  the  cut  edges  to  one  another  behind  the  testicle 
(Fig.  183),  usually  a  portion  of  the  sac  can  be  resected  with  advantage,  only 
enough  being  left  to  allow  for  easy  suturing  behind  the  epididymis  (Fig.  184). 


SURGERY  OF  THE  TESTICLES 


353 


Hemorrhage  should  be  guarded  against  by  the  clamping  of  even  the  smallest 
vessels,  preferably  before  they  are  divided,  as  they  show  a  strong  tendency  to 
retract.  When  all  bleeding  has  been  stopped,  the  testicle  is  returned  to  the 
scrotum,  and  the  skin  wound  is  sutured. 

The  purpose  of  this  operation  is  the  contacting  of  the  serous  surface  with 
connective  tissue,  that  there  may  be  no  serous  sac  in  which  serum  may  collect. 

Infantile    Hydrocele 

This  is  an  effusion  into  a  sac  formed  by  more  or  less  of  the  unobliterated 
funicular  portion  of  the  vaginal  tunic.  This  sac  is  closed  from  the  peritoneal 
cavity  above,  and  communicates  with  the  tunica  vaginalis  testis  below. 

Symptoms. — The  symptoms  are  those  of  hydrocele  extending  well  up  along 
the  cord.    The  tumor  shows  no  change  in  tension  on  recumbency. 

Treatment. — Simple  evacuation  with  the  finest  needle  of  the  aspirator  may 
be  followed  by  cure,  since  there  is  a  natural  tendency  towards  obliteration  of 
the  sac  on  evacuation  of  its  contents. 

Should  this  be  unsuccessful,  the  sac  should  be  in  part  or  completely  excised. 

Bilocular  Hydrocele 

Exceptionally  the  scrotal  hydrocele  is  bilocular, — that  is,  there  are  two 
distinct  cavities  filled  with  fluid  and  communicating  with  each  other  by  a 


Fig.  185. — Bilocular  hydrocele.  (B6raud.) 
H,  testicle;  A''. /i,  epididymis;  5,  vas;  2".i;,  cavity  of  the 
tunica  vaginalis;  D,  cavity  of  the  diverticulum;  T.c, 
tunica  vaginalis  communis;  Z,  cellular  tissue 
between  the  tunica  propria  and  the  tunica  communis. 
(Kocher.) 

comparatively  narrow  opening.  One  variety  of  this  bilocular  formation  is  de- 
scribed by  Curling  as  due  to  the  distention  of  the  visceral  portion  of  the  vaginal 
tunic  passing  between  the  body  of  the  testis  and  the  epididymis.  Normally, 
in  this  position  there  is  a  pouch,  which,  under  tension,  may  extend,  forming  a 
23 


354  GEXITO-URINARY  SURGERY      . 

tumor,  to  the  inner  side  of  the  testis;  the  opening  into  this  accumulation  is 
from  the  outer  side.  Beraud  has  described  two  cases  of  diverticular  development 
(Fig.  185)  due  to  the  lessened  resistance  of  a  certain  portion  of  the  parietal 
vaginal  tunic,  which,  yielding  to  the  pressure  of  effusion,  forms  a  distinct  pouch. 

There  is  a  perineal  form  of  bilocular  hydrocele  dependent  upon  trauma, 
causing  rupture  of  a  preexisting  hydrocele  and  an  effusion  of  the  contents  into 
the  perineum.  This  effusion  becomes  encapsulated.  These  bilocular  hydroceles 
are  usually  translucent.  They  may  be  shown  by  alternate  pressure  to  com- 
municate with  each  other. 

Another  comparatively  rare  form  of  bilocular  hydrocele — a  variation  of  the 
infantile  t}^e — occurs  as  follows:  The  funicular  portion  of  the  tunica  vaginalis 
is  commonly  obliterated  at  the  internal  ring.  Below  this  the  whole  tunica  vag- 
inalis may  be  patulous,  or  it  may  be  closed  just  above  the  position  of  the  testis. 
As  the  fluid  accumulates,  sacculation  develops,  the  tumor  extending  either  back- 
ward and  downward  into  the  pelvis,  or  more  commonly  upward  and  inward 
between  the  abdominal  muscles  and  the  peritoneum. 

Symptoms. — In  addition  to  the  ordinary  symptoms  of  hydrocele  (i.e., 
fluctuation,  dulness  on  percussion,  translucehcy,  and  smooth  surface)  there 
will  be  found  a  constriction  separating  the  tumor  into  two  portions.  Alternate 
pressure  will  show  that  these  portions  intercommunicate,  and  exceptionally, 
when  tension  is  not  great,  the  opening  of  communication  may  be  distinctly  felt. 
It  is  usually  placed  at  the  external  ring.  The  scrotal  tumor  is  smaller  than 
that  formed  in  the  abdominal  parietes.    There  is  distinct  impulse  on  coughing. 

Treatment. — Bilocular  hydrocele  is  best  treated  by  incision,  with  removal 
of  the  sac,  or  as  much  of  it  as  is  accessible.  Care  should  be  taken  to  avoid 
opening  the  general  peritoneal  cavity. 

Multilocular  Hydrocele 

Multilocular  hydrocele  of  the  testicle  may  be  hereditary  or  may  be  due  to 
inflammatory  adhesions,  which,  by  causing  agglutination  between  the  folds  of 
the  vaginal  tunic,  but  without  obliterating  it,  leave  a  number  of  cavities  into 
which  serum  can  be  exuded.  On  palpation  the  tumor  will  be  found  somewhat 
irregular  in  outline,  and  aspiration  will  evacuate  only  a  small  portion  of  its 
contents,  not  materially  diminishing  the  tension  of  the  rest  of  the  tumor. 

Treatment. — This  consists  in  the  excision  of  the  sacs.  When  excision  is 
impracticable,  the  cysts  may  be  opened  and  their  interiors  painted  with  phenol. 

Inguinal   Hydrocele 

The  hydrocele  which  forms  in  the  vaginal  tunic  of  the  undescended  testicle 
may  be  of  the  ordinary  variety  or  may  be  congenital,  communication  persisting 
between  the  vaginal  tunic  and  the  general  peritoneal  cavity.  We  have  seen  it 
distinctly  bilocular,  one  pouch  passing  upward  for  three  inches  between  the 
peritoneum  and  the  transversalis  fascia,  the  second  pouch  extending  through 
the  external  ring  and  forming  a  tumor  in  the  scrotum. 

Symptoms. — The  symptoms  are  those  already  given  as  characteristic  of 
hydrocele,  except  that  the  tumor  is  formed  in  the  inguinal  region. 

Treatment. — Since  it  is  very  difficult  to  exclude  the  presence  of  hernia, 


SURGERY  OF  THE  TESTICLES 


355 


inguinal  hydrocele  should  be  treated  by  open  incision,  the  sac  being  partly  or 
completely  removed.  Healthy  testicles  should  be  brought  down  into  the  scro- 
tum; when  marked  wasting  exists  the  appropriate  operation  is  castration. 

Fatty  Hydrocele 

This  has  been  variously  ■  described  as  chylous  or  milky  hydrocele,  and  is 
the  name  given  to  a  collection  of  fluid  resembling  milk  or  chyle  in  the  tunica 
vaginalis  testis.  It  may  be  produced  by  lymphorrhagia  following  an  actual 
rupture  of  the  lymphatic  channels  or  by  leakage  of  lymph  through  the  walls 
of  the  vessels.  This  latter  method  is  the  more  common,  and  is  dependent  upon 
obstruction  to  the  return  of  the  lymph,  either  by  an  inflammatory  process  or 
by  the  presence  of   filarise. 

It  has  been  maintained  that  the  presence  of  fat  is  due  to  degenerative 
changes  occurring  in  a  simple  hydrocele.  Whatever  the  causation,  the  density 
of  the  contained  fluid  renders  diagnosis  difficult,  since  translucency  is  lacking. 
The  other  symptoms  of  hydrocele  are  present.  If  the  effusion  is  double  and  the 
patient  is  an  inhabitant  of  a  tropical  climate,  an  examination  for  filariae  should 
be  made. 

Treatment. — Excision  of  the  sac  is  indicated. 

Congenital   Hydrocele 

This  form  of  hydrocele  depends  for  its  existence  upon  the  maintenance  of 
a  communication  between  the  tunica  vaginalis  and  the  abdominal  cavity.  The 
funicular  portion  of  the  tunic  does  not  become 
obliterated.  The  fluid  may  come  from  the 
general  abdominal  cavity  or  may  be  exuded 
from  the  vaginal  tunic.  It  may  develop  in 
early  infancy  or  not  until  later  life. 

Symptoms. — The  general  appearance  is  that 
of  a  hydrocele  of  small  size,  which  extends  up 
the  cord  into  the  inguinal  canal.  It  is  generally 
stated  by  the  patient  that  the  tumor  becomes 
srnaller  or  disappears  entirely  during  the  night, 
yet  attempts  on  the  part  of  the  physician  to 
expel  the  fluid  into  the  abdominal  cavity  are 
frequently  futile.  When  reduction  can  be  ef- 
fected, pressure  over  the  inguinal  canal  fails  to 
prevent  the  reappearance  of  the  tumor  after  the 
patient  has  assumed  the  upright  position.  Impulse  on  coughing  may  or  may  not 
be  present  (Fig.  186). 

Diagnosis. — Hernia  is  the  only  condition  with  which  congenital  hydrocele 
is  likely  to  be  confused.  The  diagnosis  is  based  on  the  greater  translucency 
of  the  latter,  the  dull  note  obtained  on  percussion,  and  the  manner  in  which 
reduction,  when  this  is  possible,  is  accomplished,  this  being  slow  and  gradual, 
usually  with  some  difficulty,  and  unaccompanied  by  the  characteristic  "  flop." 
The  gradual  reappearance  of  the  swelling,  in  spite  of  gentle  pressure  on  the  canal 
by  finger  or  truss,  also  differentiates  hydrocele  from  hernia. 


Congenital    hydrocele    with 


356  GENITO-URINARY  SURGERY 

Prognosis. — This  is  good,  as  these  hydroceles  commonly  disappear  sponta- 
neously with  obliteration  of  the  funicular  portion  of  the  vaginal  tunic. 

Treatment. — The  obliteration  of  the  vaginal  tunic  is  favored  by  the 
application  of  a  truss,  which  may  be  required  for  the  treatment  of  the  co- 
existent hernia.  In  case  the  truss  is  not  successful,  an  operation  for  the  radical 
cure  of  inguinal  hernia  should  be  performed,  with  ligation  of  the  sac  above  the 
testicle  so  as  to  form  a  tunica  vaginalis. 

HYDROCELE  OF  THE  CORD 

Acute  Hydrocele  of  the  Cord.— This  is  a  rare  condition,  seen  most  fre- 
quently in  young  subjects  after  strain.  A  translucent  swelling  forms,  containing 
fluid  resembling  that  of  ordinary  hydrocele.  The  effusion  is  limited  by  the 
investment  of  the  cord,  and  is  rather  an  acute  oedema  into  loose  cellular  tissue 
than  an  effusion  of  fluid  into  a  sac. 

MolHere  holds  that  this  acute  oedema  is  due  to  rheumatismal  'funiculitis. 
The  affection  develops  with  local  inflammatory  phenomena,  but  without  much 
pain. 

It  may  simulate  an  incarcerated  hernia,  but  may  be  distinguished  by  its 
translucency,  and  by  dulness  on  percussion  and  absence  of  abdominal  symptoms. 
The  swelling  may  involve  the  entire  cord,  transforming  it  into  a  soft  sausage- 
shaped  mass. 

Treatment. — Compresses  wet  in  lead  water  and  alcohol  and  held  in  place 
by  a  crossed  of  the  perineum  gauze  bandage  will  limit  the  swelling  and  hasten 
its  subsidence. 

Diffuse  Hydrocele  of  the  Cord. — This  is  a  general  infiltration  into  the 
cellular  tissue  enclosed  by  the  fascia  which  invests  the  cord.  The  tunica 
vaginalis  is  not  affected;  indeed,  the  funicular  portion  of  this  tunic  is  usually 
completely  obliterated.  The  etiology  is  obscure,  but  is  probably  dependent  on 
passive  exudation  from  the  veins  and  lymphatics  of  the  cord  due  to  pressure 
interference  with  return  circulation.  It  is  not  associated  with  general  oedema 
of  the  penis  and  scrotum,  since  the  fibrous  tunic  of  the  cord  entirely  separates 
this  structure  from  the  cellular  tissue  lying  beneath  the  deep  layer  of  the 
superficial  fascia. 

Symptoms. — The  tumor  forms  gradually,  with  very  few  symptoms.  It  may 
involve  the  entire  length  of  the  cord,  reaching  from  the  testicle  to  the  internal 
ring  and  filling  the  inguinal  canal.  It  is  broader  in  its  lower  portion,  and  may 
cover  the  upper  portion  of  the  testis  and  epididymis  as  a  cap.  On  placing  the 
patient  on  his  back  and  elevating  the  testicle  the  swelling  gradually  diminishes, 
but  does  not  disappear  entirely.  On  gentle  continued  pressure  deep  pitting  may 
be  detected.  The  infiltration  is  painless  unless  it  be  a  sequel  of  acute  inflam- 
mation, is  doughy  rather  than  fluctuating,  and  gives  the  test  of  translucency. 

The  differential  diagnosis  must  be  made  from  omental  hernia.  This  gives 
a  more  distinct  impulse  on  coughing,  is  not  so  smooth,  can  be  reduced  suddenly 
and  completely,  and  is  very  feebly  translucent.  In  irreducible  omental  hernias 
of  fat  people  a  preoperative  diagnosis  may  be  impossible. 

Treatment. — When  the  infiltration  produces  a  tumor  of  such  size  as  to 
cause  inconvenience  from  its  bulk,  incision  and  drainage  are  indicated. 


SURGERY  OF  THE  TESTICLES 


357 


Encysted  hydrocele  of  the  cord,  or  funicular  hydrocele,  consists  of  an 
accumulation  of  fluid  within  an  unobHterated  portion  of  the  funicular  portion 
of  the  tunica  vaginaHs.  This  accumulation  is  closed  from  the  peritoneal  cavity 
above  and  from  the  tunica  vaginalis  testis  below.  In  many  cases  swellings 
apparently  belonging  in  this  class,  on  account  of  the  difficulty  attending  their 
reduction,  in  reality  communicate  with  the  abdominal  cavity,  and  are  therefore 
of  the  congenital  type.  The  hydrocele  may  be  unilocular,  bilocular,  or  multi- 
locular,  in  the  latter  case  forming  a  series  of  small  cysts  along  the  course  of 
the  cord.  These  cysts  may  be  placed  in  the  inguinal  canal,  and  are  more 
common  on  the  right  side.  They  are  usually  observed  in  children,  and  may  be 
complicated  by  hernia  (Fig.  187). 

Symptoms.^A  smooth,  dense,  ovoid,  fluctuating  swelHng  is  formed  in  some 
portion  of  the  spermatic  cord.  By  transmitted  light  the  tumor  is  found  to  be 
translucent,  and  the  testicle  can  usually  be  recognized  below  it. 

Diagnosis. — This  is  based  on  the  position  of  the  cyst  or  cysts.  Encysted 
hydrocele  of  the  testicle,  though  sometimes  extend- 
ing upward  along  the  cord,  is  attached  to  the  testis 
and  the  epididymis.  In  hydrocele  of  the  cord  palpa- 
tion will  show  that  the  tumor  is  not  directly  con- 
nected with  the  testicle.  Hydrocele  of  the  cord  is 
distinguished  from  hernia  by  absence  of  impulse  on 
coughing,  inabiHty  to  reduce  the  tumor  entirely 
within  the  abdominal  cavity,  though  it  is  often  easily 
pressed  back  into  the  inguinal  canal,  and  absence 
of  tympany  and  gurgling.  The  hernia  is  not  trans- 
lucent. 

Treatment. — In  children  spontaneous  cure  may 
occur.  Excision  of  the  sac  is  probably  the  safest 
method  of  treatment,  and  the  one  most  certain  to 
effect  a  cure.  In  elderly  people,  where  radical 
measures  are  not  desired,  repeated  tappings  will  be  necessary  to  afford  relief. 


Fig.   187. — Inguinal  hernia,  with 
hydrocele  of  the  cord.     (Kocher.) 


HYDROCELE'  INTO  A  HERNIAL  SAC 

An  effusion  of  serum  which  may  closely  simulate  hydrocele  may  take  place 
into  the  sac  of  an  inguinal  or  a  scrotal  hernia.  This  sac  may  contain  only  fluid 
or  it  may  contain  in  addition  to  the  fluid  a  portion  of  gut  or  omentum,  the 
hernia  being  incarcerated.  There  is  always  more  or  less  effusion  in  combination 
with  incarcerated  hernia,  and  the  sac  not  infrequently  becomes  thickened  and 
fibrous,  closely  resembling  the  investment  of  chronic  hydrocele  or  a  hematocele. 
The  symptoms  are  those  of  a  hernia  followed  by  the  development  of  a  fluctu- 
ating, probably  translucent  tumor.  When  the  sac  contains  both  fluid  and 
intestinal  contents,  tenderness  and  possibly  resonance  in  the  inguinal  region 
may  lead  to  a  correct  diagnosis.  Frequently  the  diagnosis  is  made  only  after 
incision. 

Treatment. — Excision  of  the  sac  and  an  operation  for  the  radical  cure  of 
the  hernia  constitute  the  only  practical  treatment. 


358  GENITO-URINARY  SURGERY 

HEMATOCELE 

Hsematocele  is  a  collection  of  blood  or  bloody  fluid  in  the  vaginal  tunic  of 
the  testicle  or  cord  or  in  the  substance  of  either  of  these  structures.  As  is  the 
case  with  hydrocele,  the  effusion  may  be  acute  or  chronic. 

Acute  Hasmatocele  of  the  Tunica  Vaginalis 

This  affection  as  compared  with  hydrocele  is  rare.  It  may  develop  as  a  result 
of  punctured  wound  or  rupture  of  the  testis,  or  may  be  caused  by  a  blow  or  by 
violent  muscular  strain.  Svalin  noted  blood  effusion  into  the  tunica  vaginalis 
and  the  scrotal  tissues  after  severe  coughing.  There  may  be  bleeding  into  a 
previously  healthy  tunica  vaginalis;  commonly  it  is  into  a  previously  inflamed 
sac,  and  often  it  occurs  as  a  complication  of  hydrocele.  It  may  be  complicated 
by  scrotal  haematoma. 

The  development  of  acute  haematocele  (haematoma)  is  characterized  by 
severe  pain,  which  may  be  sickening  in  character,  and  the  rapid  formation  of 
a  tumor. 

This  tumor  completely  envelops  the  testicle,  and  closely  corresponds  to  it  in 
shape. 

The  blood  may  coagulate  or  remain  fluid.  The  tumor  never  reaches  large 
dimensions,  since  it  forms  so  rapidly  that  the  tunica  vaginalis  ruptures,  thus 
allowing  the  blood  to  escape  into  the  scrotal  tissues'. 

Symptoms. — The  distention  of  the  vaginal  tunic  is  usually  obscured  by  the 
concomitant  scrotal  blood  effusion.  After  this  has  been  absorbed  there  may  be 
found  a  fluctuating  tumor  impervious  to  light  and  giving  on  exploratory  punc- 
ture blood  or  blood-stained  fluid. 

Exceptionally  complete  resolution  takes  place.  Usually  the  tunica  vaginalis 
undergoes  the  alterations  characteristic  of  chronic  hydrocele. 

Treatment. — Acute  hsematocele  incident  to  trauma  is  treated  by  rest,  eleva- 
tion of  the  parts,  and  the  application  of  evaporating  lotions  or  the  ice-bag.  If 
the  swelling  is  rapid  and  progressive,  clots  should  be  evacuated  through  an 
incision,  and  a  search  made  for  the  bleeding  vessel.  The  scrotal  infiltration  is 
quickly  absorbed.  If  on  its  disappearance  the  vaginal  tunic  is  still  distended, 
its  contents  should  be  evacuated  through  a  free  incision,  since  otherwise  the 
tunica  vaginalis  becomes  chronically  inflamed  and  a  chronic  hsematocele  may 
form. 

Chronic  Haematocele  of  the  Tunica  Vaginalis 

This  affection  is  dependent  upon  chronic  inflammation  of  the  tunica  vaginaHs, 
and  is  properly  called  peri-orchitis  haemorrhagica  or  haemorrhagic  vaginalitis. 
The  blood  effusion  is  simply  a  symptom  of  such  inflammation,  which,  in  turn, 
is  generally  regarded  as  secondary  to  disease  of  the  epididymis  or  of  the  testis. 

Gosselin  recognizes  three  degrees  of  hematocele,  basing  his  classification  upon 
the  extent  of  lesion  which  the  walls  of  the  sac  show.  The  first  degree  is  char- 
acterized by  moderate  thickening,  the  vaginal  tunic  being  but  little  altered 
beyond  some  increase  in  vascularity.  There  is  a  deposit  of  thin,  nonadherent 
false  membrane.  On  evacuation  of  its  contents  the  sac  will  collapse.  The 
second  degree  is  characterized  by  increased  thickness  of  both  the  vaginal  tunic 


SURGERY  OF  THE  TESTICLES 


359 


and  the  false  membranes,  the  walls  being  too  rigid  to  collapse  on  evacuation 
of  the  contents  of  the  sac.    The  condition  is  progressive. 

The  third  degree  is  characterized  by  still  greater  thickening  and  rigidity. 
Areas  of  cartilaginous  and  calcareous  transformation  are  observed.  Barigandin 
described  a  case  of  ossification  of  the  tunica  vaginalis.  In  the  thickened  walls 
are  often  found  foci  of  soft  granulation-tissue  or  interstitial  hemorrhages. 

The  thickened  sac  is  made  up  partly  of  fibrinous  deposits  and  partly  by 
organization  of  the  infiltrate  into  the  subserous  connective  tissue  (Fig.  188). 

On  incising  a  hsematocele  blood  more  or  less  altered  or  blood  raingled  with 


Fig.   188. — Sac  of  chronic  hasmatocele.     Observe  the  thickened,  non-collapsible 
character  of  the  sac.     Adherent  to  the  interior  are  fibrinous  deposits  and  blood  coagula. 

hydrocele  fluid  is  found.  In  old  cases  the  blood  is  altered  both  in  color  and  in 
consistence,  and  may  form  a  chocolate-colored  or  black  syrupy,  or  even  a 
gelatinous  mass.  When  the  bleeding  is  into  the  sac  of  a  hydrocele  the  fluid  is 
clear  red  and  contains  clots. 

In  recent  cases  {i.e.,  those  in  which  the  sac  is  not  greatly  thickened)  the 
testicle  may  not  be  appreciably  altered,  even  though  the  tumor  is  of  great  size. 
As  induration  and  thickening,  in  consequence  of  subserous  infiltration  and 
organization,  take  place,  the  albuginea  becomes  involved,  together  wath  its 
fibrous  trabecule,  and  there  results  an  atrophy  of  the  tubules  wnth  fatty  de- 
generation of  their  epithelium.  In  the  large,  greatly  thickened,  degenerated 
sacs  careful  search  may  fail  to  discover  even  a  trace  of  the  testis. 

The,  testicle  usually  lies  in  the  lower  posterior  portion  of  the  tumor.     In 


360  GENITO-URINARY  SURGERY 

the  early  stages  of  development,  before  the  gland  has  atrophied,  palpation^ 
eliciting  testicular  sensation,  will  probably  enable  the  surgeon  to  determine  its 
exact  position.  In  the  late  stages  of  haematocele  where  the  sac  is  greatly 
thickened  it  may  be  impossible  to  determine  whether  the  testicle  lies  in  front  of 
or  behind  the  swelling.  In  such  a  case  operation  should  be  conducted  with  great 
care,  the  tissues  being  examined  before  they  are  cut. 

Chronic  haematocele  is  of  slow  formation,  and  is  most  common  between  the 
fortieth  and  the  sixtieth  years  of  age.  It  may  grow  steadily,  or  may  rapidly 
increase  in  size  after  brief  intervals  of  quiescence.  The  tumor  is  hard,  painless, 
ovoid  or  pyriform  in  shape,  with  smooth  or  bosselated  surface,  showing  at  times 
spots  of  softening  and  possibly  dense  areas  of  calcareous  degeneration. 

Diagnosis.- — This  is  founded  on  the  smooth  bossed  surface,  the  rounded  or 
oval  shape,  the  tense,  elastic  feel,  the  varying  consistence,  and  the  absence  in 
any  portion  of  the  tumor  of  either  a  projection  or  a  depression  corresponding 
to  the  position  of  the  testicle  or  the  epididymis.  There  is  usually  a  history 
of  traumatism,  strain,  or  preexisting  hydrocele.  The  general  growth  of  the 
tumor  is  slow,  but  it  exhibits  irregularly  recurring  periods  of  rapid  increase  in 
size,  attended  by  pain,  heat,  and  swelling.  These  sudden  increments  are  due  to. 
fresh  hemorrhages  into  the  sac.  The  tumor  is  not  translucent.  The  final 
diagnosis  depends  upon  aspiration.  For  the  purpose  of  thus  confirming  the 
diagnosis  a  needle  longer  than  that  employed  in  the  ordinary  hypodermic 
syringe  is  required. 

The  distinction  from  hydrocele  is  dependent  upon  absence  of  distinct  thrill 
and  fluctuation,  failure  to  detect  translucency,  and  finally  the  result  of  explora- 
tory tapping  or  incision.  -Diagnosis  from  chronic  orchitis  or  mahgnant  growths 
may  be  absolutely  impossible,  except  from  the  history.  In  case  of  doubt  there 
should  be  no  hesitation  in  deciding  the  matter  by  an  aseptic  incision. 

Prognosis. — There  is  no  tendency  towards  spontaneous  cure.  The  disease 
may,  however,  become  self-limited.  It  usually  progresses,  forming  ultimately 
a  large  tumor,  which  inconveniences  mainly  by  its  bulk  and  by  the  pain  and 
disability  dependent  upon  the  intercurrent  attacks  of  acute  inflammation.  Even 
though  the  patient  experiences  no  mechanical  incanveniences  from  the  growth, 
it  inevitably  destroys  the  secreting  function  of  the  testicle  and  predisposes  to 
suppuration  and  to  malignant  degeneration.  Suppuration  may  follow  the  use 
of  an  apparently  clean  trocar,  since  the  conditions  are  exceedingly  favorable  to 
germ-growth.  At  times  it  occurs  from  haematogenous  infection,  the  predisposing 
cause  being  trauma.  The  haematocele  and  the  scrotum  of  the  affected  side 
become  oedematous  and  painful,  the  symptoms  of  constitutional  infection  de- 
velop, and  softening  takes  place,  followed  by  grumous  discharge.  Some  cases 
of  malignant  degeneration  of  haematocele  have  been  recorded.  It  is  probable,, 
however,  that  in  these  the  haematocele  complicated  cancer  and  developed 
secondarily. 

Treatment. — Chronic  haematocele  should  be  treated  by  excision  of  the  sac, 
together  with  its  thick  lining  or  pseudomembrane.  The  wound  should  be  closed 
without  drainage. 

Incision  followed  by  curetting  is  the  simplest  and  most  easily  performed 
of  the  radical  operations,  and  is  successful  when  the  walls  of  the  sac  have  not 


SURGERY  OF  THE  TESTICLES  361 

become  extensively  infiltrated  and  rigid.  The  cavity  of  the  cyst  is  opened  by 
a  free  incision,  which,  unless  the  position  of  the  testicle  has  been  determined 
previously,  is  deepened  with  the  utmost  care.  The  contents  of  the  sac  are 
washed  out,  and  the  whole  interior  is  scraped  smooth  with  a  sharp  curette.  So 
much  of  the  outer  wall  of  the  vaginal  tunic  as  can  be  easily  freed  is  cut  away, 
and  the  remaining  portion  is  sewed  to  the  skin.  The  cavity  is  then  loosely" 
packed  with  iodoform  gauze,  and  is  allowed  to  heal  by  granulation. 

When,  because  of  great  thickening  and  rigidity,  with  cartilaginous  or  cal- 
careous deposits,  it  is  evidently  impossible  for  the  walls  of  the  sac  to  come 
together  and  become  obliterated,  or  even  to  produce  healthy  granulations, 
decortication  is  indicated.  This  is  practised  by  opening  the  tunica  vaginalis  and 
tearing  and  dissecting  away  from  it  the  thick  layers  of  false  membrane  by  means 
of  the  finger  or  by  rough  sponging;  more  often  the  knife  or  scissors  are  required. 
When  the  false  membrane  has  been  reflected  as  closely  as  possible  to  the  testis 
and  cord  without  wounding  these  structures,  it  is  cut  away,  the  edges  of  the 
vaginal  tunic  are  sutured  to  the  skin,  and  the  wound  is  lightly  packed. 

Castration  is  indicated  in  long-standing  haematoceles  in  old  subjects  when 
there  is  reason  to  believe  that  the  testicle  is  partially  or  completely  atrophied 
and  the  patient  is  not  in  a  condition  to  stand  a  prolonged  operation. 

Encysted  Haematocele  of  the  Testis 

This  is  an  extravasation  of  blood  into  an  encysted  hydrocele.  The  symptoms 
are  those  of  sudden  increase  of  a  preexisting  encysted  hydrocele,  with  inflamma- 
tory phenomena.    The  tumor  fluctuates  at  first,  but  is  not  translucent. 

Treatment. — Total  excision  of  the  sac  is  indicated 

Intratesticular  Haematocele 

This  results  from  traumatism.  After  an  injury  persistent  pain  and  swelling 
not  dependent  on  hydrocele  might  suggest  parenchymatous  effusion  of  blood, 
though,  except  by  puncture,  an  early  diagnosis  from  acute  orchitis  would  be 
impossible.  The  pain  of  these  heematomata  is  said  to  be  extremely  severe  and 
persistent.  The  detection  of  a  fluctuating  area  in  the  testicle  proper  would 
indicate  incision  and  drainage. 

Parenchymatous  haematocele  of  the  epididymis  is  reported  by  Jacobson. 

Treatment. — If,  following  testicular  trauma  properly  treated  (see  p.  313)^ 
pain  remains  intense  and  persistent,  the  testicle  showing  a  moderate  increase 
in  size  not  dependent  upon  hydrocele,  exploratory  puncture  of  this  gland  with 
the  finest  needle  of  the  aspirator  is  indicated,  since  these  symptoms  may  be 
due  to  a  hsematoma,  which,  if  allowed  to  remain,  may  produce  total  disorgani- 
zation of  the  testicle.  The  aspirating  needle  should  be  thrust  in  at  the  most 
painful  spot  or  into  any  area  of  obscure  softening  or  fluctuation,  if  this  can 
be  detected.  If  the  needle  shows  that  there  is  an  encysted  blood  effusion,  this 
should  be  opened,  the  blood  evacuated,  and  the  cavity  drained. 

Haematocele  of  the  Cord 
This  may  be  diffuse  or  encysted. 

Diffuse  h.ematocele  is  usually  due  to  rupture  of  a  vein  from  direct  trau- 
matism or  sudden  increase  of  intraabdominal  pressure.     There  forms  quickly 


362  GENITO-URINARY  SURGERY 

a  doughy,  sausage-shaped  tumor,  occupying  the  position  of  the  cord,  and  entirely 
obscuring  it.    This  tumor  is  not  translucent. 

In  the  chronic  form  of  diffuse  hcematocele  of  the  cord  the  blood  effusion  may 
reach  enormous  dimensions.  It  is  characterized  by  great  thickening  of  the 
limiting  walls. 

Treatment, — This  has  for  its  object  the  limitation  of  effusion  and  the 
prevention  of  inflammatory  reaction.  The  patient  is  put  to  bed.  A  layer  of 
cotton  is  placed  over  the  cord,  and  a  crossed  of  the  perineum  bandage  is  firmly 
applied.  If  in  twenty-four  hours  it  is  evident  that  the  bleeding  has  ceased, 
inflammatory  reaction  is  Hmited  by  evaporating  lotions  or  the  ice-bag.  Should 
bleeding  persist  in  spite  of  pressure,  incision,  securing  the  bleeding  point,  and 
closure  of  the  wound  without  drainage  are  indicated. 

Encysted  h.ematocele  of  the  cord  is  due  to  hemorrhage  into  an  encysted 
hydrocele  or  to  the  encysting,  of  a  hemorrhage  into  the  cord.  It  begins  in  the 
lower  part  of  the  cord,  forming  a  pyriform  tumor,  with  the  base  down,  which 
ultimately  may  become  merged  with  the  epididymis  and  testis. 

The  diagnosis  is  suggested  by  the  history  of  the  tumor,  especially  its  origin, 
and  the  absence  of  translucency. 

Treatment. — Incisiorj,  evacuation  of  clots,  and  decortication  or  complete 
removal  of  the  sac  are  indicated. 

LOOSE  BODIES  IN  THE  TUNICA  VAGINALIS 

It  sometimes  happens  that  on  palpation  of  the  testis  a  rather  hard  body, 
about  the  size  of  a  kidney-bean  or  smaller  than  this,  may  be  felt  moving  freely 
under  the  finger.  This  body  is  smooth  and  elastic;  its  motion  may  be  limited, 
or  may  be  so  free  that  the  body  can  be  pushed  into  any  portion  of  the  vaginal 
sac.  There  is  usually  a  moderate  degree  of  hydrocele  of  a  thickish  consistence. 
These  bodies  are  often  cysts  with  thick  walls,  sometimes  exhibiting  calcareous 
degeneration,  the  remains  of  foetal  structures;  they  originate  beneath  the  tunica 
vaginalis,  and  become  pedunculated  and  finally  free,  the  pedicle  rupturing. 
Floating  fibroid  and  cartilaginous  bodies  are  also  found;  these  grow  from  the 
subserous  connective  tissue  and  later  become  detached  and  lie  loose  in  the 
cavity.    They  are  generally  small  and  multiple. 

Symptoms. — These  bodies  are  commonly  found  accidentally,  and  cause  no 
symptoms  beyond  a  moderate  hydrocele.  If  they  cause  pain  and  acute  vagina- 
litis,  or  if  they  are  encountered  during  the  radical  cure  of  hydrocele,  they 
should  be  removed. 

NEURALGIA  OF  THE  TESTICLES 

Reference  has  been  made  already  to  the  intense  pain  which  accompanies 
inflammatory  conditions  of  the  testicle  and  epididymis.  There  may,  however, 
be  a  pain  equally  severe  which  occurs  without  apparent  cause  in  testicles  showing 
no  evidence  of  disease.  This  pain  may  be  in  the  testicle  or  may  shoot  from  this 
region  along  the  cord.  It  may  be  continuous,  or  regularly  or  irregularly  inter- 
mittent. It  is  symptomatic  of  what  Cooper  called  ''  irritable  testicle,"  and  is 
sometimes  observed  in  hysterical  patients.  Exceptionally  the  aura  of  true  epi- 
lepsy takes  the  form  of  neuralgia  of  the  testis. 


SURGERY  OF  THE  TESTICLES       .  363 

Many  cases  supposed  to  be  purely  neuralgic  are  dependent  upon  distinct 
lesion.  Thus,  the  pain  may  be  excited  by  tumors,  such  as  fibromata  or  myo- 
mata,  or  by  parenchymatous  blood-cysts,  or  by  the  congestions  incident  to 
varicocele. 

The  only  symptom  of  the  neuralgia  is  pain.  This  may  be  agonizing  in  its 
intensity,  and  may  be  associated  with  tonic  or  clonic  spasm  of  the  cremaster 
muscle.  The  testicle  is  extremely  sensitive,  even  friction  of  the  garments  or 
the  slightest  touch  causing  severe  suffering.  During  the  paroxysms  of  pain  the 
testicle  may  become  hard  and  the  vessels  of  the  cord  congested.  The  neuralgia 
may  be  dependent  upon  traces  of  a  previous  inflammation,  the  presence  of  a 
hernia,  or  certain  systemic  conditions,  as  gout,  rheumatism,  or  toxaemia.  We 
believe  that  careful  examination  will  show  that  the  majority  of  cases  are  in 
part  due  to  a  varicose  condition  of  the  spermatic  veins.  It  is  true  that  varico- 
cele may  attain  enormous  dimensions  and  yet  cause  no  pain.  Even  slight  dila- 
tation may,  however,  occasion  marked  symptoms  in  those  who  are  hereditarily 
neurotic.  Cases  which  are  unaccompanied  by  tenderness  of  the  gland  are  often 
due  to  seminal  vesiculitis  or  prostatitis.  Errors  in  sexual  hygiene,  especially 
long  periods  of  ungratified  sexual  excitement,  are  frequently  at  the  basis  of  the 
condition. 

Treatment. — The  first  thought,  in  treating  this  affection,  should  be  to 
exclude  organic  lesions,  such  as  blood-cyst,  tubercle,  hernia,  varicocele,  seminal 
vesiculitis,  and  prostatitis;  when  it  is  evident  that  pain  is  not  dependent  upon 
a  local  condition  which  may  be  remedied  by  operation,  palliative  treatment 
is  indicated.  A  great  number  of  external  applications  and  internal  remedies 
have  been  used,  and  often  successfully.  It  must  be  confessed  that  certain  cases 
resist  every  form  of  treatment.  Among  the  most  serviceable  therapeutic  meas- 
ures are  the  pressure  suspensory  bandage,  local  applications  of  heat  and  cold, 
counter-irritation,  freezing  the  overlying  skin  with  ethyl  chloride,  blisters,  gal- 
vanism, and  the  ice-bag.  Internally  there  may  be  given  aconitine  in  full  doses, 
quinine,  antipyrin,  acetanilid,  valerian,  and  hyoscine.  The  general  treatment 
should  be  hygienic  and,  if  indicated,  anti-rheumatic. 


CHAPTER  XVI 
SURGERY  OF  THE  SPERMATIC  CORD 

ANATOMY 

The  spermatic  cord  is  about  four  inches  in  length,  and  extends  from  the 
internal  abdominal  ring  to  the  globus  minor  of  the  epididymis.  It  is  made  up 
of  the  vas  deferens,  or  excretory  duct  of  the  testicle,  the  spermatic  artery  from 
the  aorta,  the  artery  of  the  vas  deferens  from  the  inferior  vesical,  the  cremasteric 
artery  from  the  deep  epigastric,  the  spermatic  veins,  the  spermatic  nerve,  plexus, 
branches  of  the  ilioinguinal  and  genitocrural  nerves,  and  lymphatics.  These 
structures  are  bound  together  by  loose  fibrous  tissue,  and  are  invested  by  the 
fasciae  carried  down  by  the  testicle  in  its  descent.  The  vas  deferens  lies  below 
and  behind  the  larger  anterior  group  of  veins  and  the  spermatic  artery.  The 
veins  of  the  cord  called  the  pampiniform  plexus  unite  into  a  single  trunk,  on  the 
right  side  passing  into  the  inferior  vena  cava  and  on  the  left  side  into  the  left 
renal  vein.  The  artery  of  the  vas  is  in  direct  relation  with  it,  while  the  sper- 
matic artery  follows  a  tortuous  course  throughout  the  cord.  The  nerves  are  dis- 
tributed throughout  the  cord,  with  the  exception  of  filaments  from  the  hj^o- 
gastric  plexus,  which  invest  the  vas  in  a  rich  net-work.  The  four  to  eight 
lymphatic  vessels  empty  into  the  glands  surrounding  the  lower  part  of  the  aorta, 
and  one  gland  lying  over  the  external  iliac  artery. 

Attention  has  been  called  to  certain  anomalies  of  the  cord.  Thus,  this 
structure  may  be  absent,  even  though  the  testicle  is  in  its  normal  place,  or  the 
two  cords  may  be  fused,  or  one  cord  may  be  double.  The  vas  may  communi- 
cate directly  with  the  ureter,  as  is  normal  at  one  period  in  foetal  life,  or  may 
be  entirely  wanting  in  its  prostatic  portion,  or  the  two  vasa  may  be  fused.  The 
single  duct  may  open  into  the  utricle,  or  may  continue  by  a  distinct  passage 
to  the  glans  penis. 

CONTUSIONS  AND  WOUNDS  OF  THE  CORD 

Contusions  rarely  cause  injury  other  than  an  acute  hsematocele,  the  blood 
which  is  poured  out  from  the  ruptured  veins  being  limited  by  the  fibrous  sheath 
of  the  cord,  thus  forming  a  sausage-shaped  tumor  which  may  extend  from  the 
testicle  to  the  internal  ring,  filling  the  inguinal  canal.  It  is  usually  associated 
with  hemorrhage  into  the  scrotal  tissue,  which  may  completely  mask  it. 

Treatment. — Rest,  elevation,  pressure,  and  the  application  of  ice  during 
the  bleeding  stage,  followed  by  evaporating  liniments,  and  possibly  massage  for 
the  purpose  of  hastening  absorption,  outline  the  treatment. 

Wounds  of  the  cord  are  necessarily  attended  by  free  bleeding,  for  the 
arrest  of  which  ligatures  are  required.  If  the  deferent  canal  is  divided,  its 
continuity  may  be  restored  by  suture.  Division  of  the  vas  is  not  followed  by 
atrophy  of  the  testicle,  even  though  the  operation  for  the  restoration  of  the  con- 
tinuity of  the  canal  is  not  performed.  When  the  spermatic  artery  is  divided, 
and  particularly  when  the  plexus  ot  nerves  supplying  the  testicle  is  extensively 
injured,  atrophy  or  gangrene  is  extremely  likely  to  result. 
364 


SURGERY  OF  THE  SPERMATIC  CORD 


365 


INFLAMMATION  OF  THE  CORD 

Funiculitis  or  inflammation  of  the  cord  may  be  acute  or  chronic. 
Acute  funiculitis  may  arise  from  extension  of  a  posterior  urethritis  along 
the  vas   (Fig.   189),  or  from  phlebitis,  especially  that  dependent  upon  rheu- 
matism.    Two  forms  of  the  affection  have  been  described,  serous  and  phleg- 
monous.    It  is  possible  that  serous  funiculitis  (diffuse  hydrocele),  which  forms 

a  rounded,  sausage-shaped,  pitting,  trans- 
lucent tumor  occupying  the  position  of 
the  cord,  is  in  reality  sometimes  an 
encysted  hydrocele.  It  occurs  as  a  com- 
plication of  gonorrhoea. 

Phlegmonous  funiculitis  is  usually 
traumatic  in  origin.  It  is  also  caused  by 
gonorrhoeal  inflammation  of  the  vas  and 
by  septic  phlebitis.  The  sausage-shaped 
tumor  is  extremely  tender,  and  may  de- 
velop with  symptoms  characteristic  of 
strangulated  hernia.  Should  the  infiltrate 
suppurate,  it  is  likely  to  invade  the  peri- 
toneal cavity  in  its  upward  extension. 

Chronic  funiculitis  is  usually 
tuberculous.  In  the  course  of  genito- 
urinary tuberculosis  the  vas  is  frequently 
infiltrated.  This  is  nearly  always  second- 
ary to  involvement  of  the  epididymis  or 
the  prostate.  Exceptionally  nodules  first 
develop  in  the  vas,  the  epididymis  being 
apparently  healthy.  Reclus  has  observed  two  such  cases;  in  one  the  nodules 
involved  the  cord  at  the  position  of  the  external  ring,  in  the  other  it  was  within 
the  inguinal  canal. 

In  the  rare  cases  of  primary  involvement  of  the  vas  the  appropriate  treat- 
ment is  excision  of  the  affected  portion  of  the  canal,  followed  by  anastomosis. 
Treatment. — Acute  funiculitis  is  treated  by  rest,  elevation,  and  the  appli-» 
cation  of  cold,  preferably  in  the  form  of  evaporating  lotions.  Should  the 
swelling  be  so  marked  as  to  threaten  the  vitality  of  the  testis,  incision  and 
drainage  are  indicated. 


Fig.  189. — ^Acute  gonorrhoeal  funiculitis. 


TUMORS  OF  THE  CORD 

Tumors  of  the  cord  may  be  either  cystic  or  solid. 

The  cystic  tumors  may  be  diffuse  or  encysted,  and  include  hydrocele,  haemato- 
cele,  spermatocele,  etc.  (see  p.  356). 

The  solid  tumors  include  lipoma,  fibroma,  fibro-lipoma,  myoma,  myxoma, 
sarcoma,  and  carcinoma. 

Lipoma  is  the  most  frequent  solid  tumor  of  the  cord.  It  may  develop  entirely 
in  the  scrotal  portion  of  this  structure,  or  may  extend  along  the  inguinal  canal 
and  into  the  pelvis.    Lipoma  may  reach  a  large  size;  Wilms  reports  one  which 


366 


GEXITO-URIXARY  SURGERY 


v/eighed  twenty  pounds.  In  the  course  of  its  growth  the  lipoma  incidentally 
becomes  distinctly  lobulated,  simulating  malignant  disease,  penetrating  between 
the  structures  of  the  cord  (Fig.  190),  and  making' entire  removal  without  sacri- 
fice pf  the  testicle  impossible;   hence  the  importance  of  early  treatment. 

Lipoma  may  undergo  myxoid  degeneration,  and  exhibit  a  tendency  to  recur 
en  removal. 

The  symptoms  are  those  of  a  painless,  slow,  somewhat  irregular,  slightly 
translucent,  soft  but  lobulated  growth  in  the  course  of  the  cord. 

The  diagnosis  from  omental  hernia 
may  be  impossible  without  exploratory 
incision.  Even  then  the  surgeon  may 
be  in  doubt,  but  may  be  guided  by 
remembering  that  the  fatty  growth  of 
an  epiplocele  is  within  the  peritoneal 
sac  and  is  often  adherent  to  it.  The 
history  of  lipoma  differs  from  that  of 
hernia,  since  it  gradually  develops  along 
the  course  of  the  cord,  grows  upward,  is 
not  reducible,  and  until  it  involves  the 
inguinal  canal  will  not  give  an  impulse 
on  coughing. 

Treatment. — Early  excision  is 
always  indicated,  since  when  the  tumor 
is  small  it  may  be  entirely  removed  with- 
out sacrificing  the  cord.  When  the 
tumor  has  reached  a  large  size  and  it  is 
impossible  to  dissect  it  free  from  the 
structures  of  the  cord,  castration  is 
indicated. 

.  Fibroma,  fibro-lipoma,  and  my- 
oma occur  rarely.  The  diagnosis  is 
usually  not  made  till  after  removal  of 
the  growth.  The  treatment  is  excision. 
Myxoma  is  rare.  It  may  be  found 
together  with  lipoma,  giving  a  semi- 
malignant  character  to  an  otherwise 
benign  tumor. 

Sarcoma  and  carcinoma  are  more 

frequent  than  myxoma.    They  both  cause  metastasis  and  develop  as  do  similar 

tumors  in  other  regions  of  the  body.    They  often  undergo  cystic  degeneration. 

The  treatment  is  castration,  with  removal  of  as  much  of  the  cord  as  possible. 

VARICOCELE 

Dilatation  and  elongation  of  the  veins  of  the  spermatic  cord  (Fig.  191)  is 
most  frequent  in  early  manhood — that  is,  from  about  the  fifteenth  to  the  twenty- 
fifth  year;  it  is  rare  in  infancy;  in  old  age  it  is  of  moderate  development  and 
causes  little  inconvenience.     The  veins  of  the  cord  are  especially  prone  to  dila- 


V 


Fig.  190. — Lipoma  of  the  cord. 


SURGERY  OF  THE  SPERMATIC  CORD 


367 


tation  and  elongation  from  the  fact  that  their  valves  are  insufficient,  and  hence 
there  is  a  long  column  of  blood  to  be  supported.  The  disease  usually  affects 
the  left  testicle  (ninety  per  cent,  of  cases),  possibly  because  the  vein,  instead 
of  passing  obliquely  into  the  vena  cava,  as  on  the  right  side,  enters  the  renal 
vein  almost  at  right  angles  to  its  long  axis,  and,  moreover,  passes  behind  the 
rectum. 

The  veins  composing  the  spermatic  plexus  can  be  ranged  in  three  groups, 
the  most  anterior  of  which  has  in  its  midst  the  spermatic  artery,  the  middle  the 
vas  deferens,  and  the  posterior  those  veins  which  pass  upward  from  the  tail  of 


Fig.  191. — Varicocele.   (Osborn.) 
Monod  and  Terrillon. 


Fig.  192. — Varicocele  of  the  left  cord;  the 
right  testicle  is  undescended. 


Ihe  epididymis.  The  anterior  group  is  the  one  first  affected,  or,  if  the  dilatation 
affects  all  the  veins,  is  most  extensively  involved.  Besides  the  mechanical 
conditions  favoring  the  development  of  variocele,  there  are  other  causes,  such  as 
prolonged  standing  or  walking,  violent  muscular  exertion,  masturbation,  sexual 
excess,  traumatism,  inflammation,  gonorrhoeal  epididymitis,  and  tumor-forma- 
tions in  the  abdominal  cavity,  particularly  swelling  of  the  lumbar  lymphatic 
glands  or  involvement  of  the  kidneys.  Hernia,  heredity,  constipation,  have 
all  been  assigned  as  etiological  factors,  but  their  influence  is  not  proved.  Billroth 
states  that  varicocele  is  due  to  a  diathesis  which  first  affects  the  vessels  of 
the  pampiniform  plexus,  and  later  those  of  the  rectum  and  the  leg. 


368  ■  GENITO-URINARY  SURGERY 

Symptoms. — The  objective  symptoms  are  as  follows:  The  scrotum  of  the 
affected  side  is  filled  with  a  tortuous  mass  of  veins,  sometimes  visible  through 
the  skin,  and  feeling  like  a  bundle  of  worms.  The  tumor  formed  by  these  veins 
partly  or  completely  disappears  on  lying  down,  but  reappears  on  standing  up, 
increasing  in  size  gradually  from  below  upward.  Pressure  exerted  over  the 
inguinal  ring  does  not  prevent  the  reappearance  of  the  tumor.  The  scrotum 
is  elongated  (Fig.  192),  may  be  dusky  purpHsh  in  color;  in  advanced  cases 
the  testicle  of  the  side  involved  is  often  markedly  atrophied. 

The  subjective  symptoms  are — (1)  pain  in  the  testicle,  the  lumbar  region, 
the  hypogastrium,  and  often  in  the  penis.  It  bears  no  relation  to  the  size  of 
the  tumor.  It  may  be  agonizing  or  simply  harassing.  (2)  Sexual  neurasthenia, 
characterized  by  mental  depression,  sexual  weakness  or  impotence,  headache, 
nervousness,  lack  of  power  of  concentrating  the  mind,  and  other  vague  general 
symptoms.     Even  quite  large  varicoceles  may  cause  no  subjective  symptoms. 

Varicocele  may  simulate  omental  hernia.  The  hernia  has  not,  however, 
the  characteristic  feeling  of  a  bundle  of  worms;  if  reduced  it  will  not  recur 
when  pressure  is  made  over  the  external  inguinal  ring,  and  it  gives  a  much 
more  distinct  impulse  on  coughing  than  does  varicocele.  The  development  of 
the  two  affections  is"  quite  different. 

Prognosis. — Varicocele  observed  in  young  men  subject  to  prolonged  and 
ungratified  sexual  excitement  is  usually  cured  by  marriage,  or,  at  least,  it  ceases 
to  give  trouble  thereafter.  If  moderate  in  degree  it  has  no  marked  tendency 
to  increase,  causes  little  pain,  and  does  not  appreciably  alter  the  nutrition  of 
the  testicle.  Quenu  states  that  owing  to  the  dilatation  of  the  veins  of  the  nerves 
there  occurs  a  periphlebitis  and  neuritis,  which  would  account  for  both  pain 
and  atrophy.  Only  when  varicocele  is  so  pronounced  that  circulation  is  mate- 
rially interfered  with  does  atrophy  of  the  testicle  result.  Spontaneous  cure 
seldom  occurs,  except  in  those  rare  acute  cases  which  develop  with  mild  inflam- 
matory symptoms  in  consequence  of  strain  or  exposure.  There  is  one  form  of 
varicocele  frequently  noted  in  old  men,  due  to  dilatation  of  the  lower  portion 
of  the  posterior  group  of  veins  and  completely  masking  the  lower  portion 
of  the  epididymis.  This  is  frequently  followed  by  sclerosis  of  the  lower  testicular 
segment. 

Treatment. — Treatment  may  be  palliative  or  radical. 

Palliative  treatment  consists  in  the  proper  regulation  of  the  bowels,  the 
avoidance  of  all  exciting  causes,  such  as  violent  muscular  efforts  or  prolonged 
standing,  the  daily  application  of  cold  douches  to  the  skin  overlying  the  dilated 
veins,  and  the  wearing  of  a  properly  fitted  suspensory  bandage.  This  treatment 
is  indicated  when  the  varicocele  is  moderate  in  size,  when  the  nutrition  of  the 
testicle  is  not  interfered  with,  and  when  the  subjective  symptoms  are  not  pro- 
nounced. 

Radical  treatment  is  indicated  when  the  varicocele  is  progressive  or  is  well 
developed,  when  beginning  atrophy  of  the  testicle  is  observable,  and  when  the 
subjective  and  reflex  symptoms,  particularly  sexual  neurasthenia,  are  pro- 
nounced. 

The  results  of  the  operation  are  usually  satisfactory.  Exceptionally  atrophy 
or  even  gangrene  of  the  testicle  follows  ligation  of  the  veins  of  the  cord.   Some- 


SURGERY  OF  THE  SPERMATIC  CORD 


369 


times  the  reflex  phenomena  are  unreHeved  or  even  exaggerated,  possibly  because 
the  neuritis  originally  caused  by  varicocele  is  progressive. 

Resection  of  the  Pampiniform  Plexus. — Excision  of  the  affected'  veins  is  best 
performed  under  ether,  though  local  anaesthesia  may  be  used.  The  operator 
by  palpation  finds  the  upper  portion  of  the  vas  and  presses  it  backward  and 
inward  away  from  the  affected  veins.  An  assistant  standing  to  the  left  of  the 
patient  makes'  firm  pressure  by  means  of  the  thumb  and  fingers  of  the  right 
hand  at  the  point  which  will  keep  the  vas  back  and  the  enlarged  veins  forward. 
The  surgeon,  passing  his  fingers  lower  down,  again  separates  the  vas  from  the 
veins,  and  the  assistant,  placing  the  palmar  surface  of  the  left  hand  beneath 
the  scrotum,  presses  firmly  with  the  thumb  and  fingers,  keeping  the  lower  part 


Fig.  193. — Resection  of  spermatic  veins  through 
an  inguinal  incision.  1,  vas;  2,  deferential  vessels;  3, 
spermatic  veins;  4,  testicle;  5,  ligatures;  6,  points  at 
which  veins  are  to  be  divided.  (From  Keen's  Surgery, 
W.  B.  Saunders  Co.) 

of  the  vas  away  from  the  group  of  dilated  veins.  By  slight  tension  with  the 
left  hand  the  skin  of  the  scrotum  is  made  taut.  The  surgeon  makes  a  longi- 
tudinal incision  two  inches  in  length  over  the  most  prominent  part  of  the 
varicocele,  dividing  the  skin,  dartos,  and  fibrous  investment  of  the  cord.  The 
veins  are  freed  by  blunt  dissection  for  two  or  three  inches  of  their  course,  and 
an  aneurism  needle,  threaded  with  catgut,  is  passed  beneath  the  entire  group 
at  the  lower  end  of  the  incision;  the  needle  is  unthreaded  and  withdrawn; 
another  needle,  similarly  threaded,  is  passed  beneath  the  veins  at  the  upper 
end;  thus  they  are  included  in  two  catgut  loops  separated  from  each  other  by 
an  interval  of  at  least  two  inches.  These  ligatures  are  tied  tightly  with  a 
triple  knot.  A  few  catgut  sutures  passed  through  the  coverings  of  the  cord 
above  and  below  the  points  where  the  veins  have  been  divided  serve  to  shorten 
the  cord  and  elevate  the  testicle.  The  skin  wound  is  closed  without  drainage. 
24 


370 


GENITO-URINARY  SURGERY 


This  operation  may  also  be  performed  through  a  transverse  incision  just 
below  the  external  ring  (Fig.  193),  as  advocated  by  Bevan. 

When  the  posterior  group  of  veins  is  markedly  involved,  forming  a  doughy 
tumor  behind  and  below  the  epididymis,  these  vessels  should  also  be  ligated 
and  excised. 

Shortening  of  the  Scrotum  and  Resection  of  the  Veins.— In  a  large  proportion 
of  cases  there  is  a  marked  elongation  of  the  scrotum  associated  with  the  venous 
enlargement.  These  cases  are  only  partially  relieved  by  the  operation  on  the 
varicocele,  so  in  such  cases  shortening  of  the  scrotum  should  constitute  a  part 
of  the  operative  procedure. 

This  is  performed  by  drawing  the  scrotum  strongly  downward,  while  an 
assistant  keeps  the  testicles  up  by  holding  the  scrotum  between  neighboring 
fingers;  or  a  Doyen  intestinal  clamp  may  be  used  in  place  of  the  fingers.    So 


Fig.  194. — Varicocele  operation.    The  lower  portion  of  the  scrotum  has  been  resected. 

much  should  be  removed  (Fig.  194)  that  at  the  conclusion  of  the  operation  the 
skin  shall  be  stretched  snugly  over  the  testicles.  As  soon  as  the  incision, has 
been  made,  scissors  being  used  for  the  purpose,  bleeding  points  are  carefully 
clamped  and  tied.  The  varicocele  is  then  dealt  with  in  the  manner  described 
above.  The  dartos  and  skin  are  then  closed  with  continuous  sutures  of  catgut 
and  silk,  starting  the  sutures  at  the  raphe. 

The  dressing  consists  of  gauze  held  in  place  by  a  crossed  bandage  of  the 
perineum,  or  an  athletic  supporter. 

VASECTOMY 

This  operation  is  employed  as  a  means  of  sterilizing  defectives  in  certain 
states.  The  vas  is  usually  most  accessible  through  the  posterior  surface  of  the 
scrotum.  It  is  isolated  from  its  surrounding  veins,  and  is  held  in  place  close 
beneath  the  skin,  which  is  stretched  tightly  over  it  by  the  two  hands  of  an 
assistant,  the  thumbs  and  forefingers  making  firm  pressure  and  holding  the  vas 


SURGERY  OF  THE  SPERMATIC  CORD  371 

away  from  the  other  structures  of  the  cord.  The  skin  overlying  the  vas  is  then 
infiltrated  with  novocaine  solution  and  is  divided;  the  fibrous  tissue  overlying 
the  vas  is  cut  through,  the  vas  itself  is  isolated  and  hooked  out  with  a  grooved 
director,  is  freed  for  an  inch,  and  a  ligature  applied  above  and  below,  and  the 
portion  lying  between  the  ligatures  is  removed.  The  wound  is  closed  by  a  stitch, 
and  the  testicle  is  enveloped  in  sterile  gauze  and  supported  by  a  crossed  of  the 
perineum  bandage. 

VASOPUNCTURE  AND  VASOSTOMY 

These  procedures  are  employed  for  the  purpose  of  medicating  and  draining 
the  seminal  vesicles,  the  former  operation  providing  for  but  a  single  medication, 
the  latter  for  repeated  applications. 

The  vas  is  isolated  as  in  the  preceding  operation.  Then,  if  a  simple  puncture 
is  to  be  made,  the  wall  of  the  vas  is  perforated  by  the  needle  of  a  hypodermic 
syringe  filled  with  the  lotion  of  choice,  usually  one  of  the  silver  preparations. 
If  vasostomy  is  to  be  performed,  an  incision  ^  to  ^  inch  long  is  made  in  the 
vas,  and  the  lips  of  this  wound  are  sewn  to  the  skin  at  the  upper  angle  of  the 
scrotal  wound,  three  or  four  sutures  running  from  the  mucosa  of  the  vas  out- 
ward through  the  skin.  If  the  suture  at  the  upper  angle  of  the  scrotal  wound 
be  of  silkworm  gut,  it  serves  as  a  guide  for  the  injection  of  lotions. 


CHAPTER  XVII 
SURGERY  OF  THE  SEMINAL  VESICLES 

ANATOMY 

The  seminal  vesicles,  two  pouches  lined  with  secreting  columnar  epithelium, 
lie  between  the  bladder  and  the  rectum,  extending  upward  and  outward 
for  approximately  two  inches  from  the  base  of  the  prostate  (Fig.  195),  to  the 
outer  sides  of  the  vasa  deferentia.  They  are  held  close  to  the  bladder  by  two 
enveloping  layers  of  fascia,  the  posterior  layer  of  which  is  in  intimate  relation 
with  the  anterior  layer  of  the  fascia  of  Denonvilliers,  which  passes  down  to 
cover  the  posterior  surface  of  the  prostate  (see  Chapter  XVIII).  Each  vesicle 
is  approximately  three-quarters  of  an  inch  wide,  and  one-quarter  of  an  inch 
thick,  the  usual  length  being  two  inches.  There  is  a  marked  difference,  how- 
ever, in  the  forms  and  sizes  of  individual  specimens.  Picker  describes  five 
main  types,  namely: 

Simple  straight  tubes 4  per  cent. 

Thick,  twisted  tubes,  with  or  without  diverticula 15  per  cent. 

Thin,  twisted  tubes,  with  or  without  diverticula IS  per  cent. 

Main  tube  straight  or  twisted,  with  larger  grape-like  arranged  diverticula 

(Fig.    196)     33  per  cent. 

Short  main  tube  with  large  irregular  ramifying  branches 33  per  cent. 

He  notes  that  the  holding  capacity  of  different  specimens  varies  from  2  cc. 
to  11.5  cc,  while  the  length  of  the  unraveled  tube  varies  from  4  to  23  cm. 

The  vesicles  contain  muscular  fibres  in  their  walls  for  the  ejection  of  their 
contents  during  intercourse. 

Below  the  vesicles  terminate  in  small  ducts  which  unite  with  the  vasa  to 
form  the  ejaculatory  ducts  (Fig.  197).  These  latter  enter  the  substance  of 
the  prostate  at  its  base,  and  passing  through  a  fascia-lined  tunnel  open  in  the 
prostatic  urethra,  usually  on  the  lips  of  the  sinus  pocularis. 

The  vesicles  receive  their  blood-supply  through  the  inferior  vesical  and 
middle  hemorrhoidal  arteries.  Their  nerves  are  derived  from  the  hypogastric 
plexus. 

Anomalies  of  the  Seminal  Vesicles. — The  seminal  vesicles  may  be  absent; 
in  this  case  there  is  usually  absence  of  the  testicles.  Unilateral  absence  has  been 
noted  in  conjunction  with  unilateral  malformations,  involving  structures  other 
than  the  testicle  or  the  cord.  Hunter  has  reported  fusion  of  the  vesicles,  the 
ducts  of  the  two  glands  uniting  and  ending  in  a  blind  pouch.  Multiple  vesicles 
have  been  observed.  Atrophy  of  the  vesicles  has  been  frequently  noted  at  post- 
mortem examination  and  quite  independent  of  any  affection  of  the  urethra  or 
the  testicles.  Communication  with  the  ureter  also  has  been  observed,  this  con- 
dition, which  obtains  during  foetal  life,  having  persisted. 

The  ejaculatory  ducts  may  be  partially  wanting,  may  be  entirely  absent,  or 
372 


SURGERY  OF  THE  SEMINAL  VESICLES 


373 


Obturator  canal 


Obturator  internus  m. 

Posterior  inferior 
spine    of    ilium 


Bladder  Ejaculatory  duct 

Prostate  gland 

Vas   deferens 


Anterior   superior 
spine  of  ilium 


Obturator  internus  tendon 

Spine  of  ischium 

WTiite    line 


Obturator  fascia 


Levator  ani  m. 

Coccygeus   m 


Recto-vesical  fascia  cut  at  its  reflection 
from  rectum  to  bladder 

Posterior  layer  of  the  triangular  ligament 
Rectum 


Tip  of  Coccyx 


Fig.  195. — Bladder,  prostate,  seroinal  vesicles,  and  vasa  deferentia.     (Deaver's  Surgical  Anatomy, 

P.  Blakiston's  Son  &  Co.) 


374 


GENITO-URINARY  SURGERY 


may  be  fused ;  they  may  pass  directly  into  the  prostatic  utricle,  or  may  continue 
forward  into  a  canal  opening  at  some  point  on  the  glans  penis,  this  condition 
giving  rise  to  the  misconception  of  a  double  urethra. 

PHYSIOLOGY 

The  functions  of  the  seminal  vesicles  seem  to  be  to  store  the  semen,  to 
dilute  it  with  the  vesicular  secretion,  and  finally  to  expel  it  into  the  prostatic 
urethra  during  sexual  intercourse.     To  insure  the  flow  of  the  spermatic  fluid 


Fig.  196. 


Fig.  197. 


Fig.  196. — Right  seminal  vesicle,  poster- 
ior surface ,  dissected  out.  1,  deferent  canal, 
with  (1')  the  ampulla;  2,  seminal  vesicle,  with 
(3)  lateral  prolongations,  (4)  cascal  dilatations, 
and  (5)  parietal  projections;  6,  union  of  the 
vesicle  with  the  vas;  7,  ejaculatory  duct;  xx 
marks  the  poGition  of  the  posterior  extremity 
of  the  undissected  vesicle.      (Testut.) 


Fig.  197. — Deferent  canal  and 
seminal  vesicle.  A,  longitudinal, 
B,  transverse  section;  1,  deferent 
canal;  2,  its  ampullated  portion; 
3,  seminal  vesicle  with  (3') 
pouches;  4,  terminal  portion; 
5,    ejaculatory    duct.       (Testut.) 


into  the  vesicle  rather  than  into  the  urethra  except  during  the  sexual  act,  the 
ejaculatory  duct  is  furnished  with  a  sphincter,  which  closes  the  duct  except 
during  coitus. 

Injuries  of  the  Seminal  Vesicles 

From  their  position  the  seminal  vesicles  are  well  protected  against  trauma- 
tism, except  that  which  is  so  extensive  that  other  lesions  overshadow  in  impor- 
tance the  injuries  to  the  vesicles. 

When  both  vasa  or  both  ejaculatory  ducts  are  divided  or  torn  it  is  extremely 
probable  that  sterility  will  result  from  obliteration.  A  wound  of  the  seminal 
vesicle  alone  is  of  minor  importance,  though  it  is  conceivable  that  it  might  be 
followed  by  fistula.  The  treatment  of  wounds  of  the  seminal  vesicles  is  con- 
ducted in  accordance  with  general  principles. 


SURGERY  OF  THE  SEMINAL  VESICLES  375 

ACUTE   VESICULITIS   OR   SPERMATOCYSTITIS 

The  usual  cause  of  this  affection  is  extension  of  gonorrhoea!  inflammation 
into  the  congested  seminal  vesicles.  It  may  be  due  also  to  infection  with  the 
ordinary  pus  microbes  and  with  the  colon  bacillus. 

Symptoms. — The  onset  of  acute  seminal  vesiculitis  is  characterized  by 
practically  the  same  symptoms  as  those  noted  in  describing  acute  posterior 
urethritis.  There  are  frequent,  straining,  painful  micturition,  and  constant  or 
shooting  pains  in  the  perineum,  hypogastric  region,  and  about  the  anus;  the 
pain  is  often  referred  to  the  hip-joint  and  sacroiliac  articulation  of  the  affected 
side,  and  may  run  down  the  outer  side  of  the  leg.  Both  direct  and  reflected 
pains  are  made  worse  by  micturition  and  defecation.  At  times  there  are  reten- 
tion of  urine  and  violent  rectal  tenesmus,  the  suffering  being  so  intense  that 
an  opiate  is  required.  Exceptionally  the  disease  is  ushered  in  with  the  ful- 
minant symptoms  of  an  acute  peritonitis.  There  are  vomiting,  tympany,  con- 
stipation, and  tenderness  over  the  whole  lower  belly-segment.  Persistent  erec- 
tions are  frequent;  painful  emissions  of  blood-stained  semen  are  not  uncommon. 
Rectal  examination  shows  at  once  a  hot,  tender,  obscurely  fluctuating  mass 
passing  upward  and  outward  from  the  prostate,  usually  about  the  size  of  the 
thumb,  with  its  upper  limit  beyond  the  reach  of  the  examining  finger.  Usually 
the  inflammatory  swelling  causes  a  bulging  of  the  entire  space  lying  above  the 
prostate  suggesting  to  the  examining  finger  an  enlargement  of  the  gland. 

Sometimes  acute  vesiculitis  develops  insidiously.  The  patient  is  not  con- 
fined to  bed,  but  may  complain  of  shooting  intermittent  pains  of  moderate 
severity  in  the  perineum,  with  rheumatic  aches  felt  in  the  hip,  sacro-iliac  joint, 
rectum,  and  perineum,  or  down  the  outer  and  inner  surfaces  of  the  leg. 

Diagnosis. — The  diagnosis  of  acute  seminal  vesiculitis  is  founded  on  rectal 
examination.  This  should  be  conducted  with  a  fairly  full  bladder,  the  patient 
leaning  forward  over  a  chair,  with  the  legs  slightly  separated;  or  he  may  be 
put  in  the  lithotomy  position  and  the  base  of  the  bladder  outlined  by  bimanual 
palpation,  the  fingers  of  one  hand  being  placed  deeply  behind  the  pubis,  while 
the  index  of  the  other  hand  is  introduced  into  the  rectum.  Palpation  is  the 
only  means  of  making  a  differential  diagnosis  from  prostatitis  or  posterior 
urethritis,  and  it  must  be  noted  that  it  does  not  enable  the  surgeon  to  distinguish 
definitely  between  spermato-cystitis  and  inflammation  of  the  ampulla  of  the 
vas.  In  both  cases  the  swelling,  at  least  during  the  acute  stage,  is  mainly  due 
to  infiltration  of  the  intertubular  and  periglandular  connective  tissue.  When  • 
both  sides  are  involved  this  infiltration  may  be  so  extensive  as  to  form  a  large 
projecting  mass  more  prominent  than  the  prostate  and  extending  from  the  outer 
border  of  one  vesicle  to  that  of  the  other,  completely  masking  the  base  of  the 
bladder.  This  condition  is  often  mistaken  for  acute  prostatitis,  but  careful 
palpation  will  outline  the  prostate  and  show  that  it  is  normal  in  size.  Usually 
the  infiltration  is  not  so  extensive,  the  inflammation  when  bilateral  forming 
two  distinct  masses.  The  pain  referred  to  the  hip-joint  seems  particularly 
characteristic  of  involvement  of  the  vesicles. 

Seminal  vesiculitis  has  been  mistaken  for  appendicitis,  and  the  symptoms 
may  be  identical.  A  history  of  urethral  discharge  would  suggest  a  rectal  exam- 
ination which  would  clarify  the  diagnosis. 


376  GENITO-URINARY  SURGERY 

Prognosis. — So  far  as  early  cure  is  concerned,  the  prognosis  must  be 
guarded,  as  suppuration  once  established  in  the  convoluted  tubule  which  makes 
up  the  bulk  of  this  gland  is  difficult  to  cure.  So  far  as  recovery  from  immediate 
symptoms  is  concerned,  the  prognosis  is  extremely  favorable,  the  disease  usually 
undergoing  partial  spontaneous  resolution  whether  treatment  is  adopted  or  not. 
There  is,  however,  a  remote  possibility  of  periglandular  suppuration,  with  the 
formation  of  an  abscess,  which  may  rupture  into  the  rectum,  the  bladder,  or 
the  peritoneal  cavity.  The  inflammation  frequently  travels  backward  along 
the  vas,  causing  epididymitis. 

The  usual  termination  of  the  affection  is  a  chronic  vesiculitis,  which  causes 
either  no  symptoms  or  those  of  urinary  or  genital  irritability,  and  which  has 
an  ultimate  tendency  to  recovery,  though  this  may  take  months  or  years. 

CHRONIC  VESICULITIS 

This  is  the  usual  termination  of  acute  inflammation.  Often  it  is  the  terminal 
stage  of  a  subacute  form  of  the  disease,  whose  onset  is  so  insidious  as  to  be 
imperceptible;  the  symptoms  of  subacute  vesiculitis  are  similar  to  those  of  the 
chronic  condition.  All  the  causes  of  pelvic  engorgement  predispose  to  its  de- 
velopment; its  indefinite  prolongation  is  probably  due  to  inadequate  drainage, 
increased  at  times  by  a  strictured  condition  of  the  ejaculatory  duct,  which  may 
become  completely  obliterated. 

Symptoms. — The  symptoms  of  chronic  vesiculitis  are  practically  those  of 
chronic  posterior  urethritis  — i.e.,  the  patient  is  subject  to  irregular  and  appar- 
ently causeless  attacks  of  frequent,  urgent  urination;  he  suffers  from  a  gleet, 
which  is  also  subject  to  exacerbations  and  remissions,  or  may  light  up  after  each 
intercourse;  mild  attacks  of  epididymitis  develop  occasionally;  there  is  often 
alteration  in  the  sexual  power  and  appetite,  and  frequently  there  are  developed 
pronounced  symptoms  of  sexual  neurasthenia,  with  pains  referred  to  the  back, 
hypogastrium,  and  thighs.  Aching  pain  in  the  testicles  is  a  not  unusual  symptom. 

Chronic  osteo-arthritis  of  gonococcal  origin  seems  oftenest  to  be  associated 
with  this  form  of  vesiculitis.  The  organisms  found  in  the  vesicles  at  this  time, 
however,  are  not  gonococci;  usually  they  belong  to  the  colon  group,  or  are  the 
ordinary  organisms  of  suppuration. 

Diagnosis. — The  diagnosis  of  chronic  vesiculitis  is  made  in  part  from  an 
examination  of  the  vesicles  with  the  finger  in  the  rectum,  and  in  part  from  an 
examination  of  the  expressed  secretion. 

To  the  palpating  finger  chronically  inflamed  vesicles  appear  slightly  denser 
than  the  surrounding  tissues,  and  may  be  distinctly  indurated.  For  the  micro- 
scopic examination  of  the  secretion,  four  to  six  ounces  of  sterile  water  or  normal 
saline  solution  should  be  placed  in  the  thoroughly  cleansed  bladder,  the  urethra 
also  having  been  irrigated,  and  the  vesicles  emptied  of  their  secretion  by  strip- 
ping them  from  above  downward  with  the  finger,  counter-pressure  being  made 
above  the  pubis  to  bring  the  organs  better  within  reach  of  the  finger.  Care 
must  be  taken  not  to  make  pressure  upon  the  prostate.  If  the  secretion 
appears  at  the  meatus  this  should  be  caught  on  a  slide  and  examined;  should 
no  secretion  so  appear  the  content  of  the  bladder  should  be  centrifuged  and 


SURGERY  OF  THE  SEMINAL  VESICLES  377 

preparations  made  from  the  sediment.  As  the  normal  secretion  contains  only- 
occasional  leucocytes,  any  excess  of  these  elements  is  an  indication  of  an  inflam- 
matory condition.  An  intimate  admixture  of  spermatozoa  is  a  strong  indication 
that  the  fluid  has  come  from  the  vesicles  or  the  ampullae  of  the  vasa,  rather 
than  from  the  prostate. 

Treatment  of  Vesiculitis. — The  prophylaxis  of  seminal  vesiculitis  consists 
in  adopting  every  possible  means  of  lessening  the  severity  of  posterior  urethritis. 
It  is  evident  that  a  comparatively  slight  amount  of  inflammatory  swelling  will 
entirely  block  the  ejaculatory  duct;  hence  irritating  injections  or  applications, 
the  passage  of  instruments,  or  any  manipulation  which  tends  to  aggravate  the 
posterior  urethritis  during  the  acute  stage  of  the  disease  should  be  avoided. 

For  the  acute  condition,  rest  in  bed,  elevation  of  the  pelvis,  rectal  injections 
of  hot  or  cold  saline  solution,  and  hot  sitz-baths  or  general  baths  are  especially 
useful  in  lessening  pain  and  congestion.  Usually  opium  and  belladonna  sup- 
positories are  required.  The  methods  described  for  chronic  vesiculitis  are  at 
times  also  applicable  to  the  acute  infection. 

In  the  treatment  of  the  chronic  condition  provision  must  be  made  for  im- 
proved drainage  of  the  organs,  and  at  times  for  medication  of  their  interior. 

Drainage  may  be  facilitated  by  massage  or  stripping  of  the  vesicles,  by 
vasostomy,  or  by  vesiculotomy.  Direct  medication  may  be  applied  through  a 
vasostomy  opening,  or,  if  but  a  single  application  is  desired,  by  exposing  the 
vas  and  puncturing  it  with  a  small  needle.  Vesiculectomy  is  demanded  but 
rarely  in  particularly  intractable  cases. 

The  evacuation  of  the  contents  of  the  vesicles  by  stripping  them  in  the 
manner  described  in  the  section  on  "  Diagnosis  "  is  the  most  generally  useful 
method  of  treatment.  It  should  be  employed  not  oftener  than  twice  a  week 
and  should  not  be  applied  with  sufficient  force  to  cause  immediate  pain  or 
secondary  inflammatory  reaction.  It  may  have  to  be  continued  for  many 
months,  and  must  always  be  supplemented  by  the  treatment  appropriate  to 
stricture  or  anterior  or  posterior  urethritis  when  these  conditions  are  also  present. 
Posterior  urethritis  is  practically  always  present  when  the  seminal  vesicles  are 
inflamed. 

Vasostomy  was  introduced  by  Belfield,  and  is  performed  in  the  manner  de- 
scribed on  page  37L  Thirty  minims  of  any  lotion  desired,  usually  one  of  the 
silver  preparations  in  a  strength  suitable  for  use  in  the  urethra,  are  injected 
with  a  syringe  armed  with  a  blunt  needle  once  or  twice  a  week,  the  medicine 
flowing  into  the  vesicle  rather  than  into  the  urethra  on  account  of  the  obstruc- 
tion offered  by  the  sphincter  of  the  ejaculatory  duct. 

Vesiculotomy  and  vesiculectomy  are  best  performed  through  a  semilunar 
or  inverted  V  incision  between  the  scrotum  and  the  anus,  the  patient  being 
in  the  high  lithotomy  position,  as  for  perineal  prostatectomy.  The  incision  is 
made  through  the  skin  and  superficial  fascia,  after  which  the  spaces  to  the  sides 
of  the  central  tendon  are  deepened  by  blunt  dissection,  the  levator  and  muscles 
being  pushed  back  and  the  transversus  perinei  forward.  The  finger  is  then 
passed  above  the  central  tendon  and  recto-urethralis  muscle,  and  these  are 
divided  close  to  the  urethra  to  avoid  injuring  the  rectum.  It  is  then  possible  to 
separate  the  rectum  from  the  prostate  and  vesicles  by  means  of  the  fingers  and 


378  GENITO-URINARY  SURGERY 

gauze  sponging.  If  then  the  rectum  be  held  back  with  a  broad  rectractor,  and 
the  prostate  be  drawn  down  by  means  of  heavy  silk  sutures  inserted  into  the 
prostatic  capsule,  one  at  each  side  of  the  base  of  the  organ,  as  recommended 
by  Squier,  it  is  possible  to  get  an  excellent  view  of  swollen  vesicles  as  they 
lie  beneath  the  fascia  of  Denonvilliers,  which  must  be  incised  for  their  attack. 
Vesiculotomy,  the  operation  usually  indicated,  is  performed  by  incising  the 
vesicles  directly  through  this  fascia,  the  incisions  being  made  wherever  there 
appear  to  be  collections  of  pus.  A  drainage-tube  is  then  sewed  into  the  largest 
incision  in  each  vesicle,  and  strips  of  gauze  are  laid  in  beside  the  tubes.  The 
tubes  are  allowed  to  remain  for  a  week  or  ten  days,  and  the  gauze  a  few  days 
longer.  In  closing  the  wound  the  levator  ani  muscles  are  drawn  together  behind 
the  drainage  material  as  after  prostatectomy. 

In  the  performance  of  vesiculectomy  the  separation  of  the  layers  of  Denon- 
villier's  fascia  is  continued  upward  till  the  extremities  of  the  vesicles  are  exposed, 
retractors  being  inserted  so  that  a  good  view  may  be  obtained.  The  fascia 
overlying  the  vesicles  is  not  incised  for  the  full  length  of  each  of  these  organs. 
In  searching  for  the  vesicles  it  must  be  remembered  that  their  tips  are  often 
widely  separated,  directed  toward  the  sides  of  the  pelvis;  should  the  fascia  be 
stripped  up  in  their  quest,  the  vesicles  will  often  be  found  adherent  to  its 
anterior  surface.  Theoretically  the  removal  of  the  pouches  is  best  effected  from 
above  downward;  practically  it  may  be  easier  to  free  the  most  accessible  portion 
first,  and  by  traction  upon  it  and  blunt  dissection  bring  within  reach  the  upper 
pole.  Care  must  be  exercised  not  to  injure  the  vas  as  the  lower  portion  is 
dissected  out;  the  ureter  is  less  likely  to  be  injured,  as  it  enters  the  bladder 
wall  at  about  the  level  of  the  upper  extremity  of  the  vesicle.  The  operation 
"has  been  followed  by  impotence. 

TUBERCULOSIS  OF  THE  SEMINAL  VESICLES 

Tuberculous  vesiculitis  is  nearly  always  secondary  to  involvement  of  the 
prostate  and  the  prostatic  urethra  or  the  epididymis,  though  clinically,  cases  are 
sometimes  observed  in  which  distinct  nodulation  of  the  vesicle  can  be  felt,  the 
prostate  being  apparently  healthy,  and  symptoms  pointing  to  involvement  of 
the  prostatic  urethra  being  absent.  The  invasion  of  these  structures  is  often 
;simultaneous.  Clinically,  we  have  many  times  noted  tuberculous  vesiculitis  pre- 
cede by  weeks  or  months  palpable  lesions  of  the  epididymis.  As  a  rule,  when 
a  tuberculous  epididymitis  becomes  demonstrable,  the  vesicle  of  the  affected  side 
is  palpably  involved. 

Tuberculous  vesiculitis  is  characterized  by  the  formation  of  a  smooth  or 
nodular,  hard  or  semi-fluctuating  tumor,  easily  detected  on  rectal  palpation. 
Both  seminal  vesicles  are  often  involved,  with  infiltration  of  the  fibrous  tissue 
lying  between  them,  forming  a  mass  practically  continuous  with  the  prostate 
and  entirely  obscuring  the  base  of  the  bladder.  The  infiltrated  mass  is  rarely 
sensitive,  and  in  the  absence  of  involvement  of  the  prostatic  urethra  may  cause 
few  symptoms,  but  sexual  erethism,  bloody  semen,  pain  during  or  after  ejacu- 
lation, and  finally  sterility  and  impotence  are  fairly  common.  The  infiltrate 
-often  breaks  down,  forming  typical  irregular  sinuses,  discharging  into  the  rectum 


SURGERY  OF  THE  SEMINAL  VESICLES  '       3/9 

and  perineum.     Tuberculous  vesiculitis  essentially  an  affection  of  the  adult. 

Diagnosis. — The  diagnosis  of  tuberculous  vesiculitis  is  founded  upon  the 
discovery  of  an  irregular,  nodulated,  non-sensitive  growth  occupying  the  position 
of  the  seminal  vesicle,  and  associated  with  other  symptoms  or  signs  of  genito- 
urinary tuberculosis,  such  as  nodulation  of  the  epididymis,  frequent  urination, 
with  passage  of  blood  and  the  finding  of  tubercle  bacilli  in  the  urine  or  the 
semen.  The  ejaculation  of  bloody  semen  in  the  absence  of  other  cause,  such 
as  gonorrhoeal  spermato-cystitis,  is  suggestive  rather  than  characteristic. 

Tuberculous  vesiculitis  occurring  in  the  course  of  gonorrhoeal  posterior  ure- 
thritis can  be  recognized  only  by  the  gradual  development  of  a  nodular  semi- 
fluctuating  tumor.     The  tuberculin  test  may  aid  in  determining  the  diagnosis. 

The  termination  is  usually  in  suppuration  and  the  formation  of  fistulous 
tracts.    Spontaneous  cure  has  been  reported  following  evacuation  of  abscesses. 

Treatment. — In  the  absence  of  symptoms,  and  when  nodulation  of  the 
epididymis  is  non-progressive,  treatment  may  be  confined  to  the  general  hygienic, 
dietetic,  and  medicinal  measures  applicable  to  tuberculosis.  As  in  all  inflam- 
mations or  infiltrations  of  the  pelvic  viscera,  regular  evacuations  from  the  bowels 
are  of  extreme  importance,  and  as  a  means  of  lessening  local  congestion  the 
urine  should  be  rendered  unirritating  and  should  be  passed  at  regular  intervals. 
If  in  spite  of  careful  treatment  inflammation  is  steadily  extending,  excision 
of  the  infiltrated  vesicle  is  indicated,  even  though  experience  has  shown  that 
a  few  of  these  cases  after  discharging  undergo  resolution. 

The  objection  to  excision  is  that  the  prostate  is  commonly  involved  in  the 
tuberculous  process,  that  the  bladder-walls  are  frequently  infiltrated,  and  that 
complete  removal  may  be  followed  by  fistula  formation. 

Great  size,  larger  than  the  last  joint  of  the  thumb,  fistula  formation,  per- 
sistent toxic  symptoms,  and  interference  with  defecation  are  the  indications 
usually  given  for  vesiculectomy.  Spontaneous  healing  may  occur  following  the 
removal  of  a  tuberculous  focus  in  the  testicle,  or  as  a  result  of  tuberculin 
treatment. 

Malignant  Growths 

These  are  secondary  to  involvement  of  the  adjoining  organs,  and'  are  ob- 
scured by  them. 

Cystic  Swelling  of  the  Seminal  Vesicles 

Usually  as  the  result  of  obstruction  of  the  ejaculatory  ducts,  conversion  of 
the  whole  vesicle  into  a  large  single  cyst  or  distention  of  one  or  more  of  its 
diverticula  may  occur;  in  the  latter  case  the  enlargement  is  made  up  of  a  num- 
ber of  small  cysts.  This  affection  may  run  its  course  without  exhibiting  symp- 
toms other  than  those  incident  to  chronic  inflammation  until  the  tumor  reaches 
sufficient  size  to  produce  pressure  effects.  Cases  are  reported  in  which  the 
cyst  reached  enormous  dimensions.  In  one  case  quoted  by  Jacobson  ten  pints 
of  brown  serous  fluid  were  drawn  off.    After  two  tappings  the  cyst  did  not  refill. 

The  diagnosis  is  based  on  rectal  palpation.  This  condition  can  scarcely  be 
differentiated  from  dermoid  cysts,  or  cysts  due  to  the  rapid  development  of  the 
remains  of  fcetal  structures. 

Treatment, — The  treatment  in  such  cases  is  aspiration,  which  may  be  twice 


380     •  GENITO-URINARY  SURGERY 

repeated.    In  case  this  fails,  permanent  drainage  may  be  established  through  a 
perineal  opening,  or  the  cyst  may  be  excised. 

Spermatocystic  Concretions 

These  concretions  are  probably  formed  originally  because  of  obstruction  of 
the  duct.  They  are  made  up  of  spermatozoa,  mucus,  and  epithelium,  and 
are  whitish  in  color,  becoming  darker  with  age  and  undergoing  calcification. 
Their  importance  lies  in  the  fact  that  they  may  occlude  the  ejaculatory  duct, 
thus  producing  sterility  and  rendering  the  cure  of  vesiculitis  impossible.  The 
symptoms  are  pain  on  emission,  associated,  perhaps,  with  the  symptoms  of 
posterior  urethritis,  such  as  frequent  urination  and  tenesmus. 

The  diagnosis  is  made  by  rectal  examination,  which  may  demonstrate  one 
or  more  hard  bodies  in  the  seminal  vesicles. 

Treatment  consists  in  breaking  up  these  concretions  by  pressure  through 
the  rectum  exerted  against  a  full-sized  sound  passed  into  the  bladder. 


CHAPTER  XVIII 


SURGERY  OF  THE  PROSTATE 

ANATOMY 

In  the  twelfth  week  of  foetal  life  five  groups  of  tubules  grow  out  from  the 
posterior  urethra,  from  the  floor  between  the  ejaculatory  ducts  and  the  bladder 
(middle  lobe),  from  the  prostatic  furrows  (lateral  lobes),  from  the  floor  beyond 
the  ejaculatory  ducts  (posterior  lobe),  and  from  the  anterior  wall  (anterior 
lobe),  to  become  the  five  lobes  of  the  prostate  gland  (see  Fig.  198).  Small 
groups  of  glands  known  as  subcervical  glands  of  Albarran  and  the  subtrigonal 
glands,  not  penetrating  deeper  than  the  submucosa  and  not  related  to  the  pros- 
tate except  by  position,  make  their  appearance  at  the  sixteenth  and  twentieth 
weeks  respectively  (Lowsley). 


Posterior 
Lob 


Lumen  of 
dder 


Trigonom 
Vesicae 


Tubule 


Fig.  198. — Sagittal  section  of  prostate  of  16-cm.  human  foetus  of  5  months;  +15. 
From  an  article  by  Lowsley,  (Journal  of  the  American  Medical  Association,  Ix,  113, 
Jan.    11,    1913). 

The  prostate  in  its  developed  form  is  a  genital  organ,  made  up  of  glandular 
tissue  with  a  considerable  admixture  of  smooth  muscular  fibres  and  connective 
tissue;  the  proportion  varies  in  different  parts  of  the  organ,  the  glandular  tissue 
being  most  marked  in  the  lateral  lobes,  and  the  muscular  and  fibrous  tissue  in 
the  preurethral  portion.  It  varies  greatly  in  size.  In  children  it  is  rudimental; 
at  the  age  of  puberty  it  grows  rapidly,  but  does  not  attain  its  full  development 
until  about  the  twenty-fifth  year;  at  about  the  fiftieth  year  there  is  a  further 
slight  increase  of  size,  due  to  hyperplasia  of  the  glandular  and  fibrous  elements, 
the  muscular  tissue  showing  rather  a  tendency  to  atrophy.  On  an  average  the 
normal  adult  prostate  has  a  length  of  3.29  cm.,  a  width  of  4.1  cm.,  and  a  thick- 
ness of  1.9  cm.  (Lowsley,  Wilson  and  McGrath,  Cuthbert  Wallace,  and  Sir  Henry 
381 


382 


GENITO-URINARY  SURGERY 


Thompson).  It  weighs  about  four  to  five  drachms.  Its  fibromuscular  capsule 
is  intimately  connected  with  the  gland  substance;  its  outer  surface  can  be  stripped 
from  the  prostatic  sheath  with  comparative  ease.  The  stroma  is  composed  of 
smooth  muscle  fibres  and  connective-tissue  elements.    Bands  of  muscle  and  con- 


VM 


Fig.  199. — Serial  cross-sections  of  prostate  from  apex 
to  base.  S,  Internal  vesical  sphincter;  SV,  seminal  vesicle; 
VD,  vas  deferens;  E,  ejaculatory  ducts;  VM,  verunion- 
tanum;  U,  utricle;  PPV,  periprostatic  plexus  of  veins;  TC, 
true   capsule   of   prostate;    FC,    false   capsule.' 

nective  tissue  pass  from  the  capsule  into  the  substance  of  the  gland,  separating 
the  lobules  and  giving  each  a  distinct  investment.  The  gland  is  made  up  of  from 
forty  to  sixty  of  these  lobules. 

In  shape  the  prostate  has  been  likened  to  a  chestnut,  a  seal-ring,  a  pyramid, 


SURGERY  OF  THE  PROSTATE  383 

but  none  of  these  similes  are  entirely  satisfactory.  The  organ  surrounds  the 
first  part  of  the  urethra  (Fig.  199),  and  is  appUed  closely  to  the  base  of  the 
bladder,  this  vesical  surface,  looking  forward  and  upward,  being  the  base  of 
the  organ,  while  the  apex  is  found  at  the  point  of  junction  of  the  membranous 
and  prostatic  urethras.  The  posterior  surface  faces  the  rectum,  and  in  many 
specimens  is  marked  by  a  median  groove.  The  border  between  the  base  and 
posterior  surface  is  separated  from  the  bladder  by  the  lower  extremities  of  the 
seminal  vesicles,  and  usually  exhibits  a  distinct  notch  at  its  midpoint. 

There  is  an  anterior  portion  of  the  prostate,  a  commissure  lying  in  front  of 
the  urethra,  consisting  mainly  of  muscular  and  fibrous  tissue,  and  of  little 
interest  from  a  surgical  standpoint ;  a  median  portion,  lying  between  the  urethra 
and  the  ejaculatory  ducts;  two  lateral  lobes  lying  to  the  sides  of  the  median 
portion,  consisting  largely  of  glandular  tissue,  and  being  the  sites  of  prostatic 
hypertrophy;  and  a  posterior  portion,  lying  behind  the  ejaculatory  ducts,  and 
described  as  the  usual  seat  of  cancerous  change. 

The  prostate  is  placed  behind  and  slightly  below  the  symphysis  pubis,  lying 
between  the  posterior  layer  of  the  triangu- 
lar ligament  and  the  neck  of  the  bladder, 
which  is  surrounded  by  its  base.  It  is 
covered  by  its  capsule,  composed  of  fibrous 
and  muscular  tissue,  while  outside  of  this 
are  reflections  of  the  rectovesical  fascia,  the 
so-called  "sheath  "  of  the  prostate,  which 
binds  it  firmly  in  its  posiiion  in  the  pelvis. 
Three  layers  of  this  fascia  are  described. 
One  passes  in  front  of  the  organ,  between 
it  and  the  pubis,  and  contains  the  venous 
plexus  of  Santorini  (Fig.  200).    The  other 

,  j_i        1    J.         1  J  Fig.    200. — Plexus   of   vessels  surrounding 

two    layers   pass    over    the    lateral    and    pOS-     the   prostate    within    the    meshes    of    the  false 

terior  aspects  of  the  gland,  being  the  two  ^^p^"^^-  ^'^^^'^^•^ 
layers  of  the  fascia  of  Denonvilliers.  The  anterior  of  these  is  adherent  to  the 
prostate,  and  contains  in  its  lateral  portions  the  periprostatic  plexus;. it  presents 
a  substantial  barrier  to  the  backward  extension  of  prostatic  carcinoma.  The 
posterior  layer  is  easily  separated  from  the  anterior,  and  is  closely  associated 
with  the  rectum. 

The  muscular  and  glandular  connections  between  the  normal  prostatic  lobes 
and  the  urethra  are  so  intimate  that  it  is  impossible  to  remove  the  former  by 
avulsion  or  blunt  dissection  without  extensive  laceration  or  destruction  of 
the  latter.  The  greater  number  of  excretory  ducts  open  upon  the  floor  of  the 
prostatic  urethra  passing  somewhat  obliquely.  Some  open  into  the  sides  or 
the  roof  of  the  canal. 

The  blood-supply  of  the  prostate  is  derived  from  the  internal  pudic,  vesical, 
and  hemorrhoidal  arteries.  The  veins  are  particularly  numerous,  and  form 
a  rich  plexus  about  the  sides,  base,  and  anterior  surface  of  the  gland.  The 
nerves  are  from  the  pudic  and  the  hypogastric  plexus. 

According  to  Lowsley,  the  lymphatic  radicals,  arising  about  the  glandular 
acini,  form  a  secondary  plexus  beneath  the  prostatic  capsule.     Several  trunks 


384  GENITO-URINARY  SURGERY 

leave  the  posterior  surface  of  the  organ,  passing  to  the  external  and  internal 
ihac  nodes,  and  to  the  lateral  sacral  nodes  and  those  of  the  sacral  promontory; 
anterior  trunks  are  joined  by  vessels  coming  from  the  membranous  and  pros- 
tatic portions  of  the  urethra,  and  run  to  the  nodes  on  the  internal  pudic  arteries. 
The  nerves  of  the  prostate  are  chiefly  sympathetic  fibres  originating  from 
the  inferior  hypogastric  plexus.  Timofeew  has  shown  that  the  prostate  contains 
a  most  elaborate  system  of  nerve-fibres  and  nerve-endings.  There  is  direct  com- 
munication between  the  nerve-supply  of  the  prostate  and  that  of  the  seminal 
vesicles.  A  few  fibres  from  the  anterior  roots  of  the  third  and  fourth  sacral 
nerves  are  present. 

PHYSIOLOGY 

The  prostate  contributes  to  the  semen  a  thin,  opalescent,  albuminous  fluid, 
containing  lecithin  bodies,  a  few  epithelial  cells  of  the  columnar  type,  amyloid 
bodies,  and  an  occasional  leucocyte.  The  purpose  of  this  fluid  seems  to  be  to 
give  the  semen  greater  volume,  and  to  render  the  spermatozoa  more  actively 
motile  and  viable  for  a  greater  length  of  time  within  the  female  genitalia. 

In  addition  to  its  secretory  function,  the  prostate  is  also  charged  with  the 
duty  of  expelling  its  secretions  during  intercourse,  and  probably  also  with  the 
expulsion  of  the  last  drops  of  urine  from  the  posterior  urethra,  in  connection 
with  the  perineal  muscles. 

The  nerve  supply  of  the  prostate  is  a  rich  one,  so  that  the  condition  of  this 
organ  exerts  a  powerful  influence  on  other  structures  and  their  functions,  par- 
ticularly those  of  the  genital  system.  It  is  not  unusual  for  infection  of  the 
prostate  to  exert  a  more  powerful  influence  on  the  mental  and  general  nervous 
condition  of  the  individual  than  an  infection  of  like  grade  in  some  other  organ. 

INJURIES  OF  THE  PROSTATE 

Contusion  of  the  prostate  is  probably  a  commoner  accident  than  is  gen- 
erally supposed.  It  may  be  caused  by  kicks  or  blows  in  the  posterior  perineum, 
or  by  jars  such  as  may  be  received  in  horseback  or  bicycle  riding.  The  symp- 
toms are  those  of  acute  prostatic  congestion — i.e.,  deep-seated  pain,  tenesmus, 
moderate  ardor  urinse,  frequency  and  urgency  of  urination,  and  sometimes  a 
sense  of  rectal  fulness.  These  symptoms  subside  in  a  few  hours  or  a  few  days, 
and,  unless  there  has  been  a  preceding  latent  lesion,  are  unattended  by  sequelae. 

The  pathological  alterations  which  take  place  from  comparatively  slight  con- 
tusions are  unknown,  since  they  never  result  fatally.  It  is  possible  that  in  the 
severer  forms  there  are  slight  multiple  parenchymatous  hemorrhages. 

Wounds  of  the  prostate,  except  those  inflicted  during  the  course  of  a 
surgical  operation,  are  of  minor  importance,  since  this  gland  is  so  placed  that 
the  vulnerating  body  which  reaches  it  almost  necessarily  involves  other  and 
more  important  structures.  Incision  into  the  prostate  practised  during  the 
course  of  surgical  operations  is  unattended  by  danger,  unless  the  rich  plexus 
of  veins  about  this  gland  is  also  involved.  The  hemorrhage  then  may  be  serious 
or  even  fatal.  From  the  prostate  itself  bleeding  is  usually  moderate,  or,  if  severe, 
is  readily  controlled  by  packing. 


SURGERY  OF  THE  PROSTATE 


385 


% 


^X 


Should  infection  occur,  wounds  of  the  prostate  may  be  extremely  dangerous, 
since  septic  phlebitis  may  result,  rapidly  extending  along  the  large,  freely  anas- 
tomosing pelvic  veins,  and  causing  septicaemia  or  pyaemia. 

Prostatic  wounds  involving  the  urethra  are  subject  to  the  dangers  of  internal 
hemorrhage  and  urinary  infiltration.  The  blood  may  flow  backward  into  the 
bladder,  filling  it  with  a  thick,  clotted  mass,  which  may  be  extremely  difficult 
to  dislodge.  If  the  bleeding  is  profuse,  a  hard,  globular  tumor  may  form  above 
the  pubis. 

Prognosis. — Wounds  of  the  prostate,  particularly  those  which  do  not  in- 
volve the  urethra,  heal  promptly,  pro- 
vided they  are  kept  clean.  When  the 
urethra  is  opened  there  is  little  danger 
of  urinary  extravasation  if  abundant 
provision  is  made  for  drainage.  These 
wounds  generally  heal  kindly,  and  are 
seldom  followed  by  urinary  fistula  or 
interference  with  micturition;  excep- 
tionally the  formation  of  a  prostatic 
cicatrix  interferes  with  the  action  of 
the  vesical  sphincter  and  causes  a  more 
or  less  permanent  condition  of  incon- 
tinence. 

When  the  prostate  is  extensively 
injured  and  the  capsular  investment 
widely  torn,  dangerous  complications, 
such  as  pelvic  cellulitis  and  even  peri- 
tonitis, may  follow.  The  lacerated 
and  contused  wounds  caused  by  un- 
skilful catheterization,  as  a  rule,  heal 
kindly,  provided  the  urine  is  not  in- 
fected. If  this  fluid  is  septic  or  if  the 
prostate  is  already  infected,  abscess 
formation,  phlebitis,  and  infiltration, 
even  ending  in  septicaemia  and  death, 
are  possible. 

Treatment. — A  wound  of  the  pros- 
tate not  involving  the  urethra  should  p^ostll"  '^"LTSn^'^Jl'^^uTetfe'^CoTi^l  itds! 

be     cleansed     and    packed    with     sterile    bulbous  urethra,  corpora  cavernosa.     (Murphy.) 

gauze.  If  in  the  course  of  twenty-four  hours  urination  becomes  difficult,  conse- 
quent upon  inflammatory  action,  a  permanent  catheter  should  be  worn  for  two 
or  three  days,  in  the  manner  described  when  treating  of  retention  of  urine  from 
enlarged  prostate.  If  the  prostatic  urethra  or  the  vesical  neck  has  been  opened, 
a  soft  catheter  should  be  passed  through  the  urethra  into  the  bladder,  and 
retained  there  for  several  days,  and  the  perineal  wound  should  be  cleansed  and 
packed.  If  it  is  impossible  to  introduce  an  instrument  into  the  bladder,  median 
perineal  urethrotomy  should  be  performed,  and  a  large,  soft  drainage-tube 
should  be  carried  through  this  opening  into  the  bladder  and  retained  there. 
If  there  is  bleeding,  the  catheter  en  chemise  should  be  introduced. 
25 


f^\  i 


\ 


\ 


k- 


386  GENITO-URINARY  SURGERY 

When  the  wound  has  been  caused  by  forced  catheterization  and  the  bladder 
is  full  of  blood,  this  should  be  withdrawn  by  suction  through  a  large  woven  or 
metal  catheter,  or  through  the  evacuating-tube  used  in  litholapaxy,  if  this 
instrument  can  be  introduced.  A  full-sized  catheter  is  then  passed  into  the 
bladder  and  is  retained  for  several  days,  the  bladder  and  urethra  being  flushed 
out  several  times  daily  with  a  mild  antiseptic  solution. 

Should  symptoms  of  local  abscess  or  septic  infection  develop,  the  prostate 
should  be  opened  by  median  perineal  urethrotomy  and  thorough  drainage  secured 
through  this  opening.  If  after  wounding  the  prostate  by  forced'  catherization 
no  instrument  can  be  introduced  into  the  bladder,  median  cystotomy  should 
be  performed.  When  hemorrhage  into  the  bladder  is  unattended  with  symptoms 
of  distention  or  local  inflammation,  surgical  intervention  may  be  delayed, 
provided  the  urine  is  sterile  and  the  urethral  instrumentation  has  been  practised 
with  proper  antiseptic  precautions.  There  is,  however,  always  a  risk  of  bac- 
terial infection:  hence  it  is  wiser  to  remove  the  clots  by  vesical  irrigation  with 
antiseptic  solutions.  The  Thiersch  solution  will  usually  suffice.  Urinary  anti- 
septics should  at  the  same  time  be  given  by  the  mouth. 

PROSTATITIS 

Inflammation  of  the  prostate  may  be  acute  or  chronic;  it  has  also  been 
classed  as  follicular,^?. e.,  confined  to  the  glands  and  periglandular  tissue, — 
or  parenchymatous,   attacking  the  entire  organ. 

Acute    Prostatitis 

Causes. — Congestion  is  a  condition  which  strongly  predisposes  to  infection, 
and  which  is  apparently  essential  to  its  development.  Congestion  may  be  due 
to  traumatism,  as  from  instrumentation  or  jarring  of  the  perineum,  excessive 
venery,  constipation,  masturbation,  prolonged  ungratified  sexual  excitement, 
hemorrhoids,  irritating  applications,  strongly  acid  or  alkaline  conditions  of  the 
urine,  urethral  calculi,  varicose  condition  of  the  prostatic  plexus,  over-distention 
of  the  bladder,  atheromatous  vessels,  chilling,  over-fatigue,  and  a  variety  of 
other  causes. 

The  immediate  cause  of  prostatitis  is  infection.  It  is  true  that  inflamma- 
tory reaction  invariably  follows  traumatism,  but  in  the  absence  of  infection 
this  undergoes  prompt  resolution.  Infection  may  be  convej^ed  along  the  urethra, 
as  in  the  case  of  gonorrhoea;  may  be  either  haematogenous  or  carried  by  the 
urine,  as  in  prostatitis  which  complicates  small-pox,  scarlet  fever,  typhus, 
typhoid,  and  other  infectious  diseases;  or  may  reach  the  prostate  by  contiguity 
of  structure,  as  from  periprostatic  suppuration. 

The  common  causes  of  acute  prostatitis  are  the  backward  extension  of 
gonorrhoeal  urethritis  and  the  introduction  of  unclean  instruments. 

Pathology. — Acute   prostatitis   is   characterized    by   increased    vascularity 

throughout  the  gland,  with  marked  dilatation  of  the  prostatic  plexus  of  veins 

(Fig.  202).    The  inflammation,  usually  beginning  in  the  mucous  membrane  of 

•  the  urethra,  extends  primarily  along  the  ducts  of  the  glands,  and  secondarily, 

when  these  have  become  obstructed,  forms  suppurating  retention  cysts,  through 


SURGERY  OF  THE  PROSTATE 


387 


the  parenchyma  of  the  organ.  Abscesses  may  appear  in  the  form  of  small  mul- 
tiple foci  or  as  large  collections.  The  small  foci  represent  the  glands  trans- 
formed to  sacs  containing  mucus,  epithelium,  and  pus,  the  ducts  being  partially 
or  completely  obstructed.  As  the  inflammatory  secretion  increases  in  quantity 
the  glandular  capsule  may  rupture,  several  of  the  suppurating  glands  becoming 
confluent,  forming  large  accumulations.  The  ejaculatory  ducts  are  always 
involved  in  the  general  catarrhal  inflammation,  and  frequently  become  occluded 
from  inflammatory  swelling  and  epithelial  proliferation.  There  results  tension 
in  the  seminal  vesicles  and  the  ampullae  of  the  vasa.  This  increases  congestion, 
and  thus  strongly  predisposes  to  further  extension  of  inflammation.  The  pros- 
tatic utricle  is  also  involved. 


Fig.  202. — Acute  catarrhal  prostatitis.  Note  the  endo-  and  peri- 
glandular round-celled  infiltration;  also  about  five  o'clock  a  dilated  capil- 
lary filled  with  the  so-called  polynuclear  round  cells.      (Rothschild.) 


Exceptionally  inflammation  extends  beyond  the  proper  capsule  of  the  gland, 
involving  the  tissues  lying  between  the  prostate  and  the  rectum,  or  even  the 
subperitoneal  connective  tissue.  This  periprostatitis  may  be  due  to  rupture  of 
the  pus  through  the  glandular  capsule,  or  to  transmission  of  infection  through 
the  medium  of  the  veins  and  lymphatics. 

The  infiltration  may  undergo  resolution  or  may  suppurate;  suppuration  is 
commonly  encountered  on  the  posterior  surface  of  the  gland, — i.e.,  between  it 
and  the  rectum.  It  may  form  an  abscess  completely  surrounding  the  vasa 
deferentia  and  the  seminal  vesicles  without  exhibiting  any  tendency  to  rupture 
into  them. 


388  GENITO-URINARY  SURGERY 

The  prostatic  inflammation  may  halt  at  any  point  in  the  course  indicated 
above.  It  may  therefore  manifest  itself  in  the  form  of  acute  hyperaemia  and 
swelling,  usually  secondary  to  acute  catarrh  of  the  prostatic  urethra;  in  that 
of  acute  folliculitis,  the  inflammation  involving  the  prostatic  ducts  and  their 
accompanying  glands,  transforming  them  into  sacs  filled  with  muco-pus;  in  that 
of  a  large  destructive  abscess  due  to  fusion  of  the  smaller  suppurating  foci;  or 
the  periprostatic  tissues  may  become  involved. 

Symptoms. — The  symptoms  of  prostatitis  vary  in  accordance  with  the 
form  and  severity  of  the  attack.  In  the  mildest  form,  characterized  by  acute 
congestion,  there  are  feelings  of  weight  in  the  perineum,  shooting  pains,  fre- 
quency of  urination,  and  possibly  difficulty  in  starting  the  stream  and  failure 
to  experience  complete  relief  after  the  bladder  is  apparently  empty,  pain  on 
defecation,  and  tenderness  and  enlargment.  When  inflammation  is  more  pro- 
nounced, the  symptoms  already  noted  are  increased  in  severity;  there  is  often 
the  sensation  as  though  a  foreign  body  were  stuffed  in  the  rectum;  urination 
is  frequent  and  urgent;  a  small  stream  is  passed  without  force,  and  often  inter- 
mittently, and  the  pain  is  severe.  When  there  is  abscess-formation  in  or 
about  the  gland  both  local  and  general  symptoms  are  usually  pronounced.  There 
is  constant  pain  in  the  perineum,  aggravated  by  urination,  defecation,  or  motion 
of  any  kind;  sitting  down  or  crossing  the  legs  is  particularly  painful.  There 
is  a  constant,  urgent,  wearing  desire  to  urinate,  each  act  of  micturition  voiding 
a  small  forceless  stream.  Defecation  may  cause  great  anguish.  Intermittent 
urethral  discharge  is  characteristic.  Painful  erections  are  frequently  observed. 
Rigors  or  chills,  followed  by  fever  and  headache,  are  nearly  constant.  As  the 
swelling  becomes  greater,  urination  is  correspondingly  more  difficult,  until  finally 
complete  retention  may  result.  Hemorrhoids  often  develop,  caused  by  pelvic 
congestion,  or  possibly  by  the  constant  straining  efforts  at  urination  which 
prostatitis  often  occasions. 

Diagnosis. — The  diagnosis  of  acute  prostatitis  is  founded  on  the  detection 
by  rectal  palpation  of  a  hot,  tender  tumor  occupying  the  position  of  the  prostate. 
This,  in  conjunction  with  some  or  all  of  the  above  symptoms,  and  especially 
with  fever  and  with  pain  which  is  especially  severe  during  defecation  and  at 
the  end  of  urination,  is  sufficient  to  establish  the  diagnosis. 

Prognosis. — The  prognosis  of  acute  prostatic  congestion,  in  the  absence 
of  infection,  is  extremely  favorable;  even  when  there  has  been  infection,  pro- 
vided the  urethra  is  free  from  abnormal  narrowing  and  there  is  no  local  or 
general  cause  for  chronic  congestion,  recovery  is  the  rule.  When  follicular  or 
parenchymatous  suppuration  has  taken  place,  the  prognosis  is  still  favorable, 
although  there  is  always  danger  of  septic  phlebitis.  The  glandular  abscesses 
commonly  rupture  into  the  urethra,  and  this  is  considered  a  favorable  termina- 
tion. So  far  as  relief  of  immediate  symptoms  is  concerned,  this  is  undoubtedly 
correct;  but  when  the  abscesses  are  of  considerable  size  this  termination  is 
less  favorable,  since  there  is  often  left  a  pouch  or  cavity  which  will  continue 
to  suppurate  indefinitely,  thus  maintaining  a  condition  of  chronic  prostatitis.  In 
such  a  pouch  urine  lodges  and  may  form  calculi,  which  ultimately  burrow  through 
the  prostate  and  cause  uro-purulent  infiltrations  of  the  surrounding  tissues  or 
fistulae. 


SURGERY  OF  THE  PROSTATE  389 

Acute  parenchymatous  prostatitis  characterized  by  rapid,  purulent  breaking 
down  of  the  entire  gland  may  result  fatally.  About  half  these  cases  rupture 
into  the  urethra. 

The  ordinary  directions  of  pointing  are  towards  the  urethra,  the  rectum, 
and  the  perineum.  The  pus  may  exceptionally  point  in  the  inguinal  or  the' 
obturator  region;  with  extreme  rarity  in  the  space  of  Retzius,  in  the  peritoneal 
cavity,  or  through  the  sciatic  foramen.  The  opening  of  such  abscesses  into 
the  recto-vesical  space  is  usually  attended  with  the  formation  of  multiple 
fistulae,  which  are  difficult  to  cure.  Ransohoff  notes  that  of  sixty-seven  cases 
twenty-one  opened  into  both  the  rectum  and  the  urethra.  The  resultant  fistula 
may  be  difficult  to  cure. 

Segond  calls  attention  to  the  frequency  of  phlebitis  when  prostatic  abscess 
is  not  properly  drained.  About  forty  per  cent,  of  the  deaths  are  due  to  this 
cause.  He  reports  the  total  mortality  as  thirty-four  in  one  hundred  and  four- 
teen cases.    This  is  not  to  be  accepted  as  the  usual  result. 

Treatment. — The  treatment  of  acute  prostatitis  consists  in  rest  in  bed, 
elevation  of  the  pelvis,  counter-irritation  or  local  depletion,  followed  by  hot 
fomentations,  a  prolonged  hot  bath,  hot  or  cold  rectal  douches  (Fig.  203),  or 
ice-bags,  the  use  of  opium  and  belladonna  suppositories,  the  internal  admin- 


FiG.  203. — Rectal  irrigator. 

istration  of  urinary  antiseptics  and  bromides,  and  the  ingestion  of  large  quantities 
of  water. 

The  diet  should  consist  principally  of  milk,  if  it  habitually  agrees  with  the- 
patient.  Hot  hip-baths  or  hot  general  baths  markedly  diminish  the  pain  and 
tenesmus,  and  may  be  administered  several  times  a  day,  the  patient  being 
subsequently  well  wrapped  up.  The  temperature  of  the  water  should  be  at 
least  105°  F.  In  the  beginning  of  the  attack  the  bowels  should  be  freely  opened 
by  salines.  After  this  there  should  be  no  effort  to  procure  evacuation  for 
several  days,  unless  there  is  reason  to  believe  that  the  rectum  is  filled  with 
faecal  matter. 

The  most  troublesome  complication  is  retention  of  urine.  This  is  overcome 
by  the  introduction  of  a  soft  catheter  under  efficient  local  anaesthesia.  \\Tien 
this  is  especially  difficult  or  painful  there  should  be  given  a  general  anaesthetic, 
and  an  instrument  having  once  been  introduced  should  be  left  in  place  until  the 
acute  symptoms  have  subsided. 

WTien  an  abscess  opens  into  the  urethra  spontaneously  or  as  the  result  of 
catheterization,  on  the  subsidence  of  acute  symptoms  every  effort  should  be 
made  to  cause  cicatrization  of  the  cavity.  If  this  is  small,  spontaneous  healing 
often  takes  place.  If  it  is  large,  suppuration  continues,  kept  up  in  a  measure 
by  the  urine,  which,  lying  in  this  sac,  decomposes,  becomes  irritating,  and  may 
deposit  calculi.    The  tendency  of  this  ulcerating  sac  is  towards  gradual  extension, 


390  GENITO-URINARY  SURGERY 

destroying  the  proper  capsule  of  the  prostate  and  causing  periprostatic  abscess 
and  extravasation  of  urine.  Obstinate  fistulae  are  likely  to  form  as  the  ultimate 
result  of  these  untreated  abscess-cavities. 

As  soon  as  the  acute  inflammatory  symptoms  have  subsided,  the  suppurating 
cavity  should  be  washed  out  twice  daily.  This  is  accomplished  as  follows: 
By  means  of  a  finger  introduced  into  the  rectum  the  prostate  is  well  milked  and 
the  abscess  emptied  of  its  pus.  The  patient  is  then  directed  to  urinate,  and 
the  urethra  and  bladder  are  irrigated  with  an  antiseptic  solution;  boric  acid  or 
.silver  nitrate  answers  well.  The  prostate  is  again  milked,  and  the  patient 
evacuates  that  portion  of  the  irrigating  fluid  which  has  entered  the  bladder. 
This  is  repeated  two  or  three  times  at  each  treatment. 

When  there  is  no  tendency  towards  the  spontaneous  evacuation  of  the  abscess 
through  the  urethra,  and  the  chills,  fever,  and  throbbing  pain  in  the  perineum 
persist,  and  there  is  marked  increase  in  the  swelling,  the  pus  should  be  evacuated 
by  perineal  incision.  There  should  be  no  hesitation  under  these  circumi^tances 
in  performing  the  operation,  since,  unless  the  abscess  ruptures  into  the  urethra, 
it  is  liable  to  burst  through  the  capsule  of  the  gland,  and  infiltrate  the  deep 
pelvic  tissues.  The  operation  should  be  conducted  under  an  anaesthetic,  the 
prostate  being  exposed  by  a  semilunar  incision  in  front  of  the  rectum,  deepened 
by  gradual  dissection.  The  focus  of  suppuration  may  then  be  detected  by  the 
exploring  needle.  When  the  tumor  is  obviously  fluctuating  it  may  be  opened 
by  a  long,  straight  bistoury  thrust  in  the  middle  line  of  the  perineum  directly 
in  front  of  the  rectum,  with  its  back  towards  this  structure  and  guided  towards 
the  abscess  by  a  finger  introduced  through  the  anus,  or  the  skin  and  superficial 
tissues  may  be  incised  as  in  the  operation  of  lateral  lithotomy,  and  the  wound 
deepened  by  means  of  a  haemostat  or  similar  blunt  instrument  thrust  through 
the  tissues  into  the  prostate  under  the  guidance  of  a  finger  inserted  into  the 
rectum,  with  less  danger  of  injuring  the  rectum  or  urethra  than  when  the 
median  incision  is  employed.  After  opening  the  abscess  the  cavity  should  be 
drained  either  by  gauze  packing  or  by  tubes.  Urethral  fistula  occasionally 
follows,  but  usually  closes  spontaneously. 

The  treatment  of  periprostatitis  and  periprostatic  abscess  is  the  same  as 
that  described  as  applicable  to  prostatitis.  The  pus  is  apt  to  point  in  the 
posterior  or  anal  perineum  and  to  invade  the  ischiorectal  space,  inasmuch  as 
its  origin  is  behind  the  middle  perineal  fascia. 

Chronic  Prostatitis 

Following  an  acute  attack  of  prostatitis,  or  secondary  to  posterior  urethritis 
or  cystitis  without  a  history  of  an  acute  attack,  the  prostate  may  become  chron- 
ically inflamed.  The  exciting  cause  is  infection;  the  predisposing  cause  con- 
gestion. This  congestion  may  be  due  to  long-continued  ungratified  excitement, 
excessive  coitus,  masturbation,  hemorrhoids,  habitual  constipation,  irritating 
conditions  of  the  urine,  or  any  of  the  conditions  which  have  already  been  men- 
tioned as  causing  pelvic  engorgement. 

The  pathology  of  the  affection  varies.  There  is  practically  always  chronic 
posterior  urethritis.     Associated  with  this  there  may  be  a  catarrhal  condition 


SURGERY  OF  THE  PROSTATE 


391 


of  the  prostatic  glands,  attended  by  distinct  dilatation  of  their  ducts  and  acini 
and  marked  thickening  of  the  peri-glandular  tissue  (Fig.  204),  or  there  may- 
be one  or  many  abscesses  discharging  into  the  prostatic  urethra  through  open- 
ings insufficient  for  thorough  drainage.  These  are  attended  by  general  engorge- 
ment, and  ultimately  result  in  the  development  of  fistulse,  or  in  cicatricial  de- 
formity or  atrophy  of  the  prostate. 

Symptoms. — The  symptoms  of  chronic  prostatitis  may  be  of  a  genital  or 
urinary  character,  or  the  disease  may  manifest  itself  by  painful  impulses  referred 
to  more  or  less  distant  regions  of  the  body. 

Symptoms  of  a  genital  character  are  of  most  frequent  occurrence,  and  usually 
indicate  a  condition  of  hyperirritability  of  the  sexual  centres,  though  less  fre- 
quently cases  are  encountered  in  which  responsiveness  is  below  the  normal ;  thus 
premature  ejaculation  is  the  most  common  symptom  of  this  group.  Other  genital 
symptoms  are  prostatorrhoea,  imperfec- 
tion or  absence  of  erections,  diminished 
vigor  of  erections,  frequent  nocturnal 
emissions,  and  painful  ejaculations. 

The  most  frequent  single  symptom  of 
chronic  prostatitis  is  frequency  of  urina- 
tion. Pain  during  the  act,  and  urgency  of 
desire,  are  also  common  complaints,  so 
that  the  picture  presented  differs  but 
little  from  that  of  acute  or  subacute 
posterior  urethritis.  On  the  other  hand, 
the  symptomatology  may  indicate  a 
mechanical  interference  with  the  per- 
formance of  the  act,  the  patient  com- 
plaining of  slow  or  difficult  urination, 
dribbling,  or  of  inability  to  completely 
empty  the  bladder,  as  in  prostatic  hyper- 
trophy. The  two  types  of  urinary 
symptoms  are  probably  due  to  the  influence  of  the  inflamed  gland  on  the  urethra 
which  it  encircles,  and  to  the  morphological  changes  produced  by  the  develop- 
ment of  fibrous  tissue,  or  possibly  by  interference  with  the  codrdination  of  the 
urethral  muscles. 

The  rich  nerve  supply  of  the  prostate,  fibres  coming  from  the  thoracic, 
lumbar,  and  sacral  segments  of  the  cord,  is  probably  responsible  for  the  large 
number  of  locations  in  which  pain  may  be  felt  as  a  result  of  prostatic  disease. 
The  lumbar  region,  the  sacro-iliac  articulation,  the  perineum,  the  urethra, 
especially  just  back  of  the  meatus,  the  rectum,  the  testicles,  and  the  thighs, 
especially  their  posterior  and  outer  surfaces,  are  examples  of  the  sites  of  reflex 
pain.  Usually  the  pain  is  a  steady  ache,  but  occasionally  it  has  a  spasmodic 
character,  so  that  it  has  been  mistaken  for  the  pain  of  ureteral  colic. 

Prostatitis  may  also  produce  certain  toxic  manifestations,  incident  to  the 
absorption  of  the  products  of  inflammation,  characterized  by  the  production  of 
arthritic  pains,  or  by  the  development  of  a  distinct  neurasthenia,  hypochondriac 
symptoms  usually  being  a  prominent  feature. 


Fig.  204. — Chronic  prostatitis.  The 
prostatic  glands  and  ducts  are  distended  with 
inflammatory  products ;  the  acinal  epithelial  cells 
have  completely  desquamated;  the  surrounding 
fibrous  stroma  is  dense  and  thick. 


392  GEXITO-URINARY  SURGERY 

Diagnosis. — The  character  of  the  prostate  as  determined  by  rectal  pal- 
pation, and  especially  the  microscopic  appearance  of  the  expressed  secretion, 
are  relied  upon  in  making  a  diagnosis  of  this  condition.  To  the  palpating  finger 
the  gland  may  appear  either  enlarged  or  diminished  in  size,  the  former  being 
the  more  frequent  condition,  while  the  consistency  is  less  uniform  and  harder. 
In  place  of  the  normal  smooth  surface  a  nodular  condition  is  often  found.  As  a 
result  of  periprostatic  inflammation,  the  gland  may  seem  to  extend  upward  and 
outward  a  greater  distance  than  is  normally  the  case. 

The  secretion  of  the  prostate  is  secured  by  massaging  the  organ  as  described 
in  the  section  on  treatment  of  prostatitis,  collecting  it  as  it  appears  at  the 
meatus,  or  recovering  it  by  means  of  the  centrifuge  from  fluid  voided  after 
massage.     The  prostatic  secretion  should  contain  but  very  few  leucocytes,  so 


Fig.  205.- — -Secretion  from  case  of  chrorjic  infection 
of  the  vesicles  and  prostate.  Note  large  masses  of  pus, 
mimerous  microorganisms,  and  few  degenerated  sperma- 
tozoa.    Urethral  epithelium  is  also  present. 

that  the  presence  of  more  than  one  or  two  pus-cells  to  the  field  (Ye  inch  ob- 
jective) is  an  indication  of  the  presence  of  prostatitis  (Figs.  205  and  206),  pro- 
vided the  presence  of  pus  from  other  sources  has  been  rendered  unlikely  by 
careful  irrigation  of  the  urethra  and  bladder,  and  by  avoidance  of  pressure 
on  the  vesicles  during  the  massage.  The  normal  prostatic  secretion  is  an  opal- 
escent, homogeneous  fluid,  alkaline  to  litmus  but  acid  to  phenolphthalein. 
Under  the  microscope  it  has  a  somewhat  granular  consistence,  due  to  the  pres- 
ence of  lecithin  bodies,  with  a  small  number  of  round  cells  with  large  nuclei 
from  the  prostatic  tubules,  and  a  very  few  leucocytes  and  amyloid  bodies  with 
concentric  striations.     Flat  cells  from  the  urethra  may  also  be  observed. 

Prognosis. — In  chronic  prostatitis  the  lesions  of  which  are  mainly  con- 
gestive, with  follicular  catarrh  not  yet  having  developed  to  distinct  abscess- 
formation,  there  is  a  tendency  towards  spontaneous  cure.  Small  abscess-cavities 
also  heal.    The  larger  sacs  show  no  such  tendency.     They  are  rather  inclined 


SURGERY  OF  THE  PROSTATE 


393 


slowly  to  extend,  causing  periprostatic  abscess  and  urethro-rectal  or  urethro- 
perineal fistulae,  often  complicated  by  calculi.  In  cases  characterized  by  symp- 
toms so  slight  as  to  excite  no  attention,  the  condition  may  remain  latent,  though 
slowly  progressive  for  years,  causing  untimately  the  atrophied  prostate  and 
sclerosed  and  contracted  internal  vesical  sphincter  which  induce  the  most  invet- 
erate forms  of  prostatism. 

Treatment. — On  beginning  the  treatment  of  chronic  prostatitis  the  patient 
should  be  informed  that  cure  is  slow  and  difficult  and  is  dependent  upon  per- 
sistence in  the  use  of  appropriate  therapeutic  measures  and  faithful  observance 
of  the  laws  of  health.  General  directions  are  given  in  regard  to  diet,  exercise, 
and  hours  of  sleep.  The  urine  is  rendered  bland  and  slightly  antiseptic.  The 
bowels  are  regulated  by  enemata  or  paraffin  oil;   erotic  excitement  is  to  be 


Fig.    206. — Secretion     of    acute      prostatitis.     Vesicular 
secretion   is    also   present. 

avoided,  though  ordinary  sexual  intercourse  need  not  be  forbidden.  It  is  un- 
doubtedly true  that  many  cases  of  chronic  prostatitis  would  be  cured  by  hygiene 
alone  if  it  included  regular  and  unemotional  sexual  gratification.  Unfortunately, 
the  majority  of  these  patients  are  young,  unmarried  adults,  and,  even  if  the 
question  of  morals  were  set  aside,  it  would  not  be  possible  for  them  to  secure 
sexual  relations  that  would  meet  their  requirements.  Hip-baths  of  a  tempera- 
ture and  duration  governed  by  the  sensations  of  the  patient  are  useful.  Rectal 
lavage  with  hot  or  cold  normal  saline  solution  should  be  used  daily.  The  use 
of  the  cold  jet  by  meahs  of  the  bidet  is  markedly  beneficial  in  many  cases. 

Digital  massage  of  the  prostate  is  the  most  valuable  single  procedure  at  our 
command,  its  virtue  lying  in  the  expression  of  the  morbific  contents  of  the 
gland  and  in  the  ensuing  betterment  in  the  circulation  of  the  blood  and  lymph. 
For  the  treatment  the  patient  should  stand  with  his  feet  apart,  knees  straight,, 
bending  forward  from  the  hips  so  that  the  trunk  is  at  right  angles  with  the  thighs^ 


394  GENITO-URINARY  SURGERY 

the  hands  being  placed  on  the  seat  of  a  chair.  The  surgeon  should  sit  behind 
and  a  little  to  the  left  of  the  patient,  and  should  have  the  forefinger  of  his 
right  hand  protected  by  a  rubber  finger  cot  and  thoroughly  lubricated.  In 
introducing  the  finger  care  should  be  taken  to  avoid  the  anal  hairs,  to  follow 
the  direction  of  the  canal  (first  toward  the  umbilicus,  and  then  backward  along 
the  sacrum),  and  to  make  all  movements  slowly,  steadily,  and  without  force. 

After  ascertaining  the  size  and  general  conformation  of  the  organ  by  gently 
sweeping  the  finger  over  it,  the  massage  is  applied  by  making  pressure  upon 
various  portions,  starting  above  and  at  the  outer  sides,  and  gradually  working 
downward  and  toward  the  midline.  When  difficulty  is  experienced  in  reaching 
the  upper  portion  of  the  gland  it  will  be  found  helpful  to  rest  the  elbow  on 
the  right  knee,  placing  the  foot  on  the  round  of  a  chair  if  necessary  to  bring 
the  knee  to  the  proper  height,  making  pressure  with  the  muscles  of  the  hip 
rather  than  with  those  of  the  shoulder.  Making  pressure  downward  with  the 
left  hand  on  the  bladder  through  the  abdominal  wall  is  also  helpful  in  sorne 
cases. 

Massage  should  be  immediately  followed  by  the  voiding  of  the  four  to  six 
ounces  of  urine  of  other  fluid  which  should  be  in  the  bladder  during  the  treat- 
ment, and  an  irrigation  of  the  urethra  and  bladder  by  hydrostatic  pressure  to 
free  them  from  prostatic  secretion. 

Prostatic  massage  may  also  be  administered  with  the  aid  of  mechanical 
vibrators  by  applying  the  instrument  to  the  knuckle  of  the  palpating  finger. 

The  interval  between  treatments  should  be  from  three  to  ten  days.  It  is 
applicable  whether  pus-cavities  are  present,  or  whether  there  is  merely  a  catar- 
rhal inflammation.  The  massage  should  not  be  painful,  and  should  be  followed 
by  a  feeling  of  added  comfort. 

Local  applications  to  the  prostatic  urethra  are  generally  indicated  for  the 
relief  of  the  accompanying  posterior  urethritis.  These  are  selected  and  applied 
in  accordance  with  the  principles  already  laid  down,  but  should  be  used  cau- 
tiously, since  reactionary  swelling  may  entirely  close  the  urethral  opening  of 
a  chronic  abscess,  causing  retention  of  pus,  extension  of  parenchymatous  inflam- 
mation, and  septic  absorption.  If  the  reaction  following  the  use  of  weak 
instillations  is  unusually  prolonged  and  severe  they  should  be  discontinued. 

The  treatment  of  urinary  retention,  with  its  painful  complications  and  fatal 
sequelae  dependent  on  sclerosis  of  the  internal  vesical  sphincter  secondary  to 
chronic  prostatitis,  requires  overdilatation  or  section  of  the  obstructing  ring. 
Prostatectomy,  though  often  performed  for  the  relief  of  this  condition,  is  not 
indicated. 

IRRITABLE  PROSTATE 

This  is  a  condition  characterized  by  repeated  rather  sudden  and  acute 
engorgements  of  the  prostate,  usually  dependent  upon  an  abnormal  condition 
of  the  urine,  such  as  excessive  acidity,  and  is  usually  associated  with  arterio- 
sclerosis. The  attack  is  often  precipitated  by  surface  chilling,  exhaustion,  con- 
stipation, or  by  alcoholic  or  sexual  excess.  It  is  probable  that  it  does  not  attack 
the  perfectly  healthy  prostate.  It  has  been  so  often  observed  in  gouty  patients 
that  the  manifestations  of  this  form  of  irritability  are  in  them  called  prostatic 
gout. 


SURGERY  OF  THE  PROSTATE  395 

The  symptoms  are  those  of  the  first  stage  of  acute  prostatitis.  There  develop.^ 
often  in  the  night  urgent,  frequent,  painful  urination.  There  may  be  steady  or 
shooting  pain  felt  in  the  perineum,  testicles,  or  back.  On  rectal  examination 
the  prostate  is  hypersensitive.  In  gouty  patients  the  urine  is  extremely  acid 
and  contains  an  excess  of  mucus.  The  symptoms  attain  their  maximum  severity 
during  the  night,  and  the  prostate  remains  sensitive  for  some  time.  This  condi- 
tion of  irritability  may  be  the  first  step  in  the  development  of  C3^stitis  or  calculus- 
formation. 

Diagnosis. — An  irritable  prostate  is  distinguished  from  an  inflamed  gland 
by  rectal  palpation  and  examination  of  the  urine.  Inflammation  is  always 
accompanied  by  the  formation  of  pus  and  by  marked  increase  in  the  size  of 
the  prostate.  The  diagnosis  of  prostatic  gout  depends  upon  the  constitutional 
history  of  the  patient  and  examination  of  the  urine. 

Treatment. — The  irritable  prostate  is  amenable  to  treatment  directed  to 
the  relief  of  congestion.  A  prolonged  hot  bath,  free  emptying  of  the  lower 
bowel  by  a  hot  soapsuds  enema,  and  a  hypodermic  injection  of  morphine  best 
control  the  acute  attack.  Acid  or  irritating  conditions  of  the  urine  should  be 
remedied,  sexual  excess,  constipation,  and  the  well-recognized  causes  of  pelvic 
congestion  should  be  avoided,  and  the  prostatic  circulation  should  be  strength- 
ened by  massage,  hot  rectal  injections,  and  the  appHcation  of  electricity.  The 
medicinal  treatment  is  directed  to  the  equalization  of  circulation  and  the  general 
strengthening  of  the  patient.  Hyoscy amine  sulphate  (grain  ^/oqo)  by  mouth 
twice  a  day  seems  to  be  helpful. 

TUBERCULOSIS  OF  THE  PROSTATE 

Tuberculosis  may  be  primarily  in  the  prostate  or  secondary  to  involvement 
of  organs  either  adjacent  or  remote.  The  proportion  of  cases  in  which  the 
disease  is  primary  in  the  prostate  is  not  known,  since  there  have  been  few 
opportunities  offered  for  postmortem  examination  until  tuberculosis  has  been 
widely  diffused.  There  have,  however,  been  a  sufficient  number  to  prove  that 
the  first  manifestation  of  the  disease  may  appear  in  the  prostate  gland.  This 
gland  is  particularly  susceptible  to  infection  of  all  kinds,  Weigert  having 
proved  that  it  is  involved  in  the  majority  of  cases  of  pyaemia  and  septicaemia. 
Tubercle  bacilli  have  been  found  in  the  apparently  healthy  prostate. 

Tuberculous  prostatitis  is  commonest  in  the  prime  of  life.  It  is  often  pre- 
disposed of  by  posterior  urethritis;  at  least  the  histories  of  many  of  these  cases 
show  that  tuberculous  involvement  followed  gonorrhoea.  It  is  evident  that  any 
of  the  causes  of  prostatic  congestion  may  thus  predispose  to  the  local  develop- 
ment of  tuberculosis.  The  morbid  anatomy  of  tuberculous  prostatitis  is  that 
characteristic  of  tuberculous  involvement  in  general — i.e.,  exuberant  granula- 
tion, central  degeneration,  and  caseation.  The  tubercles  are  first  lodged  in  the 
walls  of  the  glandular  ducts,  extending  through  a  part  or  the  whole  of  the 
gland,  and  ultimately  either  undergoing  encapsulation  or  absorption,  a  rare  ter- 
mination, or  softening  and  breaking  down,  forming  abscess-cavities. 

The  prostate  is  usually  enlarged  from  inflammatory  congestion;  abscess- 
formation  takes  place  slowly  but  surely.  Exceptionally  the  lesions  develop  in 
the  lower  outer  portion  of  the  gland  near  the  rectum;  usually  they  are  observed 


396  GENITO-URINARY  SURGERY 

near  the  urethra.  In  this  case  ulcers  are  formed  which  steadily  extend.  Ab- 
scesses developing  in  the  substance  of  the  gland,  though  occasionally  sclerosing 
and  healing,  commonly  enlarge  steadily,  opening  into  the  urethra,  the  rectum, 
the  perineum,  or  even  the  hypogastrium,  and  forming  multiple  fistulous  tracts. 
Tuberculosis  of  the  prostate  becomes  generalized  slowly.  Usually  a  mixed 
infection  supervenes,  the  colon  bacillus  and  the  various  staphylococci  being 
the  organisms  generally  present. 

Symptoms. — The  symptoms  of  tuberculous  infiltration  of  the  prostate  are 
practically  those  of  chronic  prostatitis,  and  are  probably  dependent  upon  involve- 
ment, or  at  least  secondary  congestion,  of  the  prostatic  urethra.  The  patient 
complains  of  frequent,  often  urgent,  urination,  and  a  slight  continuous  or  inter- 
mittent, glairy,  mucopurulent  discharge  from  the  meatus.  Shreds  are  constant 
in  the  urine;  there  may  be  a  discharge  after  defecation  or  even  after  each  act 
of  urination;  somtimes  one  or  two  drops  of  blood  are  passed  at  the  end  of 
urination,  and  attacks  of  acute  or  subacute  prostatitis  are  excited  by  slight  and 
apparently  insufficient  causes.  When  the  parenchymatous  or  peripheral  por- 
tion of  the  gland  is  involved  there  may  be  no  symptoms  for  a  long  time,  or 
the  patient  may  note  slight  pain  during  defecation  and  burning  pain  after- 
wards. In  certain  cases  the  disease  appears  to  begin  as  an  acute  parenchy- 
matous prostatitis.  On  the  subsidence  of  the  early  inflammatory  symptoms 
nodulation  may  be  felt. 

Diagnosis. — This  is  based  on  finding  the  tubercle  bacilli  in  the  discharge 
milked  from  the  prostate,  on  the  detection  of  thickening,  nodulation,  or  points 
of  softening  on  rectal  examination,  and  on  the  discovery  of  tuberculous  involve- 
ment of  the  epididymis  or  the  seminal  vesicles.  The  infiltration  sometimes 
spreads  wide  of  the  prostate,  forming  a  large,  irregular,  diffuse  mass  entirely 
obscuring  the  outlines  of  the  prostate  and  vesicles.  The  tuberculin  test  is  often 
of  assistance. 

Prognosis. — This  is  grave.  Spontaneous  cure  by  a  process  of  sclerosis, 
though  possible,  is  rare. 

Treatment. — The  treatment  should  be  directed  towards  improving  the 
general-  health  of  the  patient,  and  is  practically  that  appropriate  to  pulmonary 
tuberculosis.  Therapeutic  injections  of  tuberculin  should  be  carefully  employed. 
As  a  rule,  local  instrumentation  and  applications  should  be  avoided,  with  the 
exception  of  instillations  of  mercuric  bichloride  (1  to  6000).  These  may  be 
employed  as  directed  in  the  treatment  of  tuberculous  cystitis,  and  are  service- 
able only  when  the  infiltration  begins  in  the  urethra  or  in  the  ducts  of  the 
glands.     Silver  nitrate  is  particularly  to  be  avoided. 

In  conducting  local  treatment  it  must  be  remembered  that  tuberculous 
infiltration  especially  predisposes  the  involved  portions  of  the  prostate,  and  the 
bladder,  which  also  often  shows  tuberculous  lesions,  to  the  invasion  of  the 
ordinary  pus  microorganisms:  hence  special  antiseptic  precautions  should  be 
taken  in  the  use  of  instruments. 

Incision  is  indicated  when  an  abscess  develops  which  threatens  to  form  a 
fistula.  The  prostate  should  be  fully  exposed  by  the  semilunar  incision  in 
front  of  the  anus,  and  all  the  diseased  tissue  should  be  removed  by  the  curette, 
the  urethra  not  being  opened  if  it  is  possible  to  avoid  this.     The  wound  is 


SURGERY  OF  THE  PROSTATE 


39.7 


treated  by  packing  with  iodoform  gauze.  Abscesses  opening  into  the  urethra 
are  kept  clean  by  irrigation.  Retention  of  urine  is  relieved  by  continuous 
catheterization  or  suprapubic  drainage. 


HYPERTROPHY  OF  THE  PROSTATE 

Hypertrophy  of  the  prostate  consists  in  an  overgrowth  of  the  normal 
cellular  constituents  of  the  gland  taking  place  in  one  or  more  of  its  lobes.  At 
the  beginning  of  the  overgrowth  the  change  in  form  is  best  expressed  by  what 
Thompson  calls  an  unnatural  tendency  to  rotundity.  The  gland  is  increased 
in    thickness    rather    than    in    other 


dimensions,  the  lateral  lobes  encroach- 
ing to  some  extent  upon  the  urethral 
lumen.  If  the  enlargement  is  pro- 
gressive it  is  likely  to  be  somewhat 
irregular,  certain  portions  of  the  gland 
increasing  more  rapidly  than  others. 
The  bulk  of  the  hypertrophy  may  be 
in  the  median  or  either  of  the  lateral 
lobes,  or  in  any  combination  of  these 
(Figs.  207,  208,  209,  and  210).  En- 
largements of  the  median  lobe  are 
probably  not  as  common  as  has  been 
supposed,  many  of  the  obstructive 
growths  lying  in  the  midline  having 
their  origin  in  the  subcervical  glands 
of  Albarran  and  in  the  subtrigonal 
group,  as  pointed  out  by  Lowsley. 
Hypertrophy  of  the  anterior  lobe  is 
very  rare.  In  fact,  Taudler  and  Zuck- 
erkandl,  basing  their  opinion  on  ex- 
tensive and  careful  anatomical  studies, 
have  recently  claimed  that  the  hyper- 
trophy of  the  gland  always  begins 
strictly  in  the  middle  lobe  or  that 
portion  of  gland  between  the  urethra 
and  ejaculatory  ducts. 

In  its  overgrowth  the  prostate  may  be  greatly  enlarged  and  soft,  indicating 
a  preponderance  of  glandular  overgrowth,  glandular  hypertrophy  (Fig.  211); 
may  be  moderately  enlarged,  or  even  small  and  hard,  suggesting  an  excessive 
stromal  proliferation,  particularly  of  the  connective-tissue  elements,  fibromuscular 
hypertrophy,  or  may  represent  a  combination  of  these  two  types.  In  the 
majority  of  cases  in  which  both  glandular  and  fibromuscular  increases  are 
present  the  glandular  tissue  is  in  excess.  The  hypertrophy  usually  takes  the 
form  of  spheroids  within  the  lobes,  growing  progressively,  and  gradually  com- 
pressing the  remaining  prostatic  tissue,  which  forms  a  capsule  about  the  enlarg- 
ing portion,  within  which  enucleation  may  be  performed.  The  spheroids  are 
less  marked  in  fibromuscular  enlargements,  and  in  a  form  of  diffuse  glandular 
hypertrophy  sometimes  encountered.     In  such  cases  enucleation  is  therefore 


Fig.    207.- 


—Hypertrophy    of    median    lobe    of 
(From  the   Department  of  Surgical 
Pathology,    University   of   Pennsylvania.) 


the  prostate. 


398  GENITO-URINARY  SURGERY 

much  more  difficult,  as  the  Hne  of  cleavage  is  not  so  distinct,  the  prostate 
having  to  be  separated  from  its  capsule. 

The  direction  of  growth  may  be  towards  the  bladder,  the  urethra,  or  the 
rectum.  When  the  overgrowth  is  limited  to  the  middle  lobe,  a  projecting  intra- 
urethral  or  intracystic  sessile  or  pedunculated  mass  is  formed  (bar  at  the  neck 
of  the  bladder),  which  may  seriously  interfere  with  urination.  The  anterior 
commissure  (isthmus)  is  only  exceptionally  involved.    Hypertrophy  commonly 


Fig.  208. — Hypertrophy  of  the  left  lateral  and  median  lobes  of  the 
prostate,  causing  trabecular  hypertrophy  and  dilatation  of  the  bladder. 
(Museum    of    Pathology,    University    of    Pennsylvania.) 

involves  the  three  lobes  and  is  progressive,  though  somewhat  unevenly,  in  all. 
Its  projection  upward  and  backward  is  incident  to  lessened  resistance,  the 
fascial  investment  limiting  its  downward  and  forward  growth. 

As  to  the  amount  of  overgrowth,  this  varies  within  wide  limits.  The  tumor 
may  be  little  larger  than  normal,  or  may  reach  the  size  of  an  orange  or  even 
of  a  cocoanut. 

Far  more  important  than  the  position  and  size  of  the  growth  are  the  altera- 
tions it  causes  in  the  length,  direction,  and  calibre  of  the  prostatic  urethra, 
and  in  the  patulousness  of  the  neck  of  the  bladder.     In  consequence  of  the 


SURGERY  OF  THE  PROSTATE 


399 


increase  in  thickness  and  the  upward  and  backward  growth  of  the  lateral  lobes, 
the  transverse  diameter  of  the  urethra  is  lessened,  and  its  length  is  increased 
in  some  cases  by  as  much  as  three  and  one-half  inches.  If  the  growth  is  asym- 
metrical, the  canal  will  be  deflected  from  its  regular  curve.  Thus,  if  the  median 
portion  enlarges  more  rapidly  than  the  lateral  lobes  the  floor  of  the  urethra  is 
lifted  up,  forming  an  abrupt  projection,  which  effectually  prevents  the  intro- 
duction of  the  ordinary  silver  catheter.  When  one  lateral  lobe  is  developed  more 
than  another  there  is  lateral  deviation,  with  the  concavity  of  the  curve  towards 
the  most  affected  side.  ,- 


Fig.  209. — Hypertrophy  of  the  median  and  one  lateral  lobe  of  the 
prostate,     a,  niterureteral  bar.     (Watson.) 

The  posterior  commissure  growing  backward  into  the  bladder  may  become 
pedicled,  forming  a  true  valve;  commonly  it  is  sessile.  The  lateral  lobes  may 
project  backward  about  the  vesical  neck  in  the  form  of  multiple  tumors  which 
encroach  upon  the  vesical  cavity  and  lift  the  neck  above  the  level  of  the  base, 
forming  two  vesical  pouches,  one  above  and  in  front,  behind  the  pubic,  the  other 
below  the  prostate  in  the  bas-fond.  The  lower  pouch  is  usually  caused  by  over- 
growth of  the  median  lobe.  Between  the  ureters  there  is  normally  an  inter- 
ureteral  bar,  made  up  of  muscular  fibres,  not  distinguishable,  except  by  dis- 
section, in  the  normal  bladder;  this  bar  becomes  greatly  hypertrophied  in 
enlarged  prostate  because  of  the  frequent  straining  efforts  to  expel  urine  from 
the  region  in  which  it  is  apt  to  accumulate  and  cause  irritation. 


400 


GENITO-URINARY  SURGERY 


Pathology. — Section  of  an  enlarged  prostate  shows  upon  examination  a 
series  of  projecting  spherical  lobulations  which  can  be  readily  shelled  out  from 
the  surrounding  tissues.     These  fibro-adenomatous  masses  vary  from  the  size 


Fig.  210. — Various  forms  of  hypertrophy  of  the  prostate.  A,  slight  symmetrical  enlarge- 
ment of  lateral  lobes;  B,  hypertrophy  of  median  lobe  only;  C,  moderate  hypertrophy  of  both 
lateral  and  middle  lobes;  D,  hypertrophy  of  lateral  and  valvular  type  "enlargement  of  median 
lobe;"  E,  excessive  enlargement  of  lateral  lobes;  F,  e.xcessive  hypertrophy  of  both  lateral  and 
median  lobes. 

of  a  pea  to  that  of  an  egg,  and  represent  overgrown  lobules,  each  with  its  fibro- 
muscular  investment  and  glandular  centre. 

The  chief  characteristic  of  a  microscopic  section  from  the  average  enlarged 
prostate  is  glandular  hyperplasia.     The  ducts  and  acini  may  be  dilated,  and 


SURGERY  OF  THE  PROSTATE 


401 


the  latter  coalescent,  and  lined  with  either  a  single  layer  of  epithelium  or  so 
filhd  with  cells  as  to  simulate  cancer.  INIalignant  degeneration  of  an  enlarged 
prostate  has  been  frequently  observed  by  Albarran,  and  when  the  epithelial 
cells  are  observed  breaking  through  the  basement  membrane  and  infiltrating 
the  stroma  the  diagnosis  of  beginning  cancer  can  be  made  with  some  certainty. 


^^'l^Wf.m  *  f /Ti '-  ^■'^ 


,*""ife*^a^ 


,.*  >- 


^1 


Fig.  211— Glandular  hypertrophy  of   the 
prostate. 


Fig.  212 — Prostatic  hypertrophy. 
Acini  filled  with  desquamated  epithelial 
cells   and   corpora   amylacea. 


The  epithelial  lining  of  both  the  ducts  and  acini  may  entirely  disappear,  and 
the  latter  may  be  represented  by  fibrous  tissue.  The  acini  are  at  times  dis- 
tended with  inflammatory  products,  forming  multiple  chronic  abscesses  in  the 
substance  of  the  gland,  or  they  may  be  filled  with  their  own  secretion  (Fig.  212), 
which  exhibits  a  tendency  to  form  concretions. 

The  stromal  outgrowth  is  usually  made  up  of  an  increase  in  connective 
tissue,  the  smooth  muscular  fibres  exhibit- 
ing a  tendency  to  disappear,  though  true 
myomatous  overgrowths  have  been  ob- 
served. There  are  scattered  through  it 
areas  of  round  cell  infiltrate,  suggesting 
inflammation  (Fig.  213), 

There  is  no  evidence  to  show  that  the 
small  hard  prostate  is  a  secondary  stage 
of  the  large  soft  enlargement,  nor  that  the 
type  characterized  by  gland  hyperplasia 
becomes  ultimately  converted  into  the  form 
which  exhibits  predominance  of  fibroid 
tissue.  Each  form  seems  to  begin  and  to 
progress  independently.  The  pathological 
changes  in  the  bladder,  ureters,  and  kidneys,  incident  to  prostatic  outgrowth 
(Figs.  214  and  215),  are  those  incident  to  obstruction  in  old  men,  whose  blad- 
ders are  undergoing  muscular  degeneration  and  have  already  been  described. 
(See  page  60.)  They  lead  inevitably  to  renal  insufficiency,  the  terminal  stage 
of  which  is  usually  heralded  by  a  rapid  gastro-intestinal  breakdown. 
26 


Fig.  213. — Hypertrophy  of  the  prostate. 
Showing  acinus  surrounded  by  marked  round- 
celled  infiltration. 


402 


GENITO-URINARY  SURGERY 


Etiology. — The  evidence  derived  from  the  more  recent  pathological  studies 
of  the  prostate  gland  points  somewhat  to  the  dependence  of  this  condition  upon 
chronic  inflammation  which  remains  latent,  in  so  far  as  symptoms  are  concerned. 
Irregularly  distributed  through  the  stroma  there  is  practically  always  a  round 
cell  infiltration,  most  marked  about  the  urethra;  in  the  stroma  surrounding  the 
ducts  and  acini  are  seen  either  fibroblasts  or  true  cicatrices. 

Against  the  inflammatory  theory  of  prostatic  enlargement  it  may  be  said 
that  it  is  a  disease  of  declining  years,  having  been  rarely  observed  before  the 
age  of  forty-five,  that  no  relation  can  be  traced  between  its  development  and  a 


Fig.  214. — Prostatic  obstruction  with  hypertrophy 

of  the  bladder-wall  and  contraction  of  its  cavity.     (Speci- 
men in  Museum  of  Philadelphia  Hospital.) 

history  of  preceding  acute  or  chronic  prostatitis,  that  thirty-three  per  cent, 
of  men  above  sixty  show  some  evidence  of  enlargement,  and  that  the  prostates 
of  practically  all  men  past  middle  age  are  shown  on  microscopical  study  to  be 
subject  to  the  same  adenomatous  change  which  in  its  more  complete  develop- 
ment is  called  prostatic  hypertrophy. 

The  dependence  of  prostatic  enlargement  upon  general  atheroma  remains 
to  be  proved,  though  it  is  undoubtedly  true  that  these  two  elements  are  often 
associated  and  are  common  at  the  same  period  of  life. 

There  is  a  variety  of  overgrowth  in  which  the  prostate  becomes  hard,  showing 
little  alteration  in  shape  or  size,  but  giving  rise  to  marked  obstruction  which 
may  have  for  its  cause  a  general  sclerosis,  though  it  is  more  probably  due  to 
fibroid  degeneration  following  chronic  inflammation. 


SURGERY  OF  THE  PROSTATE 


403 


Syimptoms. — The  symptoms  of  enlarged  prostate  are  mainly  dependent  upon 
interference  with  the  function  of  micturition:  hence  it  is  possible,  when  the 
overgrowth  occupies  such  a  position  in  the  gland  as  not  to  interfere  with  the 
calibre,  dilatabihty,  or  direction  of  the  urethra,  that  it  may  attain  large  pro- 
portions before  any  symptoms  are  excited.  As  soon  as  the  tumor  grows  in 
such  a  direction  or  reaches  such  size  that  the  urethral  calibre  is  distinctly 
encroached  upon,  the  patient  will  notice  that — (1)  Micturition  is  unduly  fre- 
quent, this  frequency  being  most  marked  during  the  night  or  in  the  early 
morning.  (2)  There  is  some  delay  in  starting 
the  stream,  and  this  does  not  flow  with  its  wonted 
force,  falling  almost  directly  from  the  penis 
without  the  customary  parabolic  curve.  (3) 
There  is  a  tendency  to  dribble  on  the  comple- 
tion of  the  act  of  micturition. 

Provided  infection  does  not  take  place,  with 
the  development  of  posterior  urethritis  and 
cystitis,  these  may  be  the  only  symptoms  of 
which  the  patient  complains  until  the  distention 
of  the  bladder  reaches  such  a  point  that  incon- 
tinence of  retention  develops.  As  a  rule,  long 
before  this  there  are  set  up  a  certain  amount  of 
urethritis  and  cystitis.  There  are  then  added  to 
the  obstructive  symptoms — i.e.,  frequency,  most 
marked  at  night,  slowness  in  starting  the  stream, 
loss  of  force,  and  dribbling — the  symptoms 
of  inflammation.  These  may  appear  in  the 
form  of  a  sensation  of  weight,  of  a  weak  and 
tired  feeling,  of  an  ache  which  may  be  steady 
or  intermittent,  or  sharp  or  dull  pains  may 
be  felt  in  the  perineum,  scrotum,  hypogastric 
region,  groins,  inner  surfaces  of  the  thighs,  back, 
and  testicles.  Later  there  are  pains  above  the 
pubis  and  sharp,  shooting  pains  in  the  urethra 
behind  the  glans  penis.  Urination  becomes 
excessively  frequent  and  painful,  is  attended 
with  violent  straining,  and  is  suddenly  and 
frequently  interrupted;  the  stream  is  small  and 
broken.  The  urine  becomes  alkaline  and  offen- 
sive, is  turbid  with  pus  and  mucus,  and  there  is  often  a  muco-purulent  urethral 
discharge. 

Frequency  of  urination  in  cases  with  non-infected  bladders  is  due  to  re- 
sidual urine.  This  occupies  the  space  that  should  be  taken  up  by  fresh  secretion 
from  the  kidneys,  and  hence  causes  the  bladder  to  become  distended  sooner  than 
would  be  the  case  normally.  The  amount  of  residual  urine  is  proportionate  to 
the  degree  of  obstruction,  and  as  it  increases  in  quantity  it  causes  gradual  dis- 
tention of  the  bladder-walls,  with  atrophy  and  degeneration  of  the  vesical 
muscles,  nearly  always  preceded  by  hypertrophy  incident  to  the  efforts  made 
to  overcome  resistance. 


Fig.  215. — Prostatic  obstruction. 
Effect  on  bladder  and  kidneys.  (Speci- 
men in  Museum  of  Philadelphia  Hos- 
pital.) 


404  GENITO-URINARY  SURGERY 

The  frequency  of  urination  in  the  absence  of  inflammation  is  proportionate 
to  the  degree  of  vesical  distention.  This  symptom  is  especially  distressing 
because  it  is  most  pronounced  during  the  night,  in  advanced  cases  compelling 
the  patient  to  rise  every  half-hour.  Nocturnal  frequency  has  been  ascribed 
to  the  more  irritating  nature  of  the  urine  secreted  at  night  and  to  the  increase 
in  the  quantity  secreted.  This  may  be  true  in  part,  but  it  may  be  doubted  if 
urination  is  really  much  more  frequent  in  the  night  than  in  the  day.  All  night 
disturbances  make  a  much  deeper  impression  than  those  by  day,  and  anxiety 
exaggerates  a  few  disturbances  into  a  constant  series.  It  must  be  borne  in 
mind  that  when  the  patient  micturates  once  during  the  night  it  is  significant, 
and  the  gravity  of  this  significance  increases  with  the  frequency  of  the  act. 

Residual  urine,  and  hence  frequent  urination,  are  more  marked  and  earlier 
symptoms  when  there  is  hypertrophy  projecting  backward  from  the  median 
portion  of  the  prostate.  Owing  to  the  altered  relation  produced  by  the  over- 
growth of  the  neck  of  the  bladder,  a  pouch  is  formed  about  the  outlet.  In. 
this  a  certain  amount  of  urine  is  contained  which  the  bladder  musculature  is 
unable  to  expel.  This  pouch  increases  in  size  as  the  bladder  becomes  dis- 
tended, until  a  condition  of  chronic  tension  is  reached,  characterized  by  incon- 
tinence, which  in  elderly  men  is  nearly  always  indicative  of  retention. 

Loss  of  force  in  the  stream  is  due  in  part  to  atony  and  degeneration  of  the 
bladder-muscles,  in  part  to  the  urethral  obstruction.  Slowness  in  starting 
micturition  and  dribbling  on  the  completion  of  the  act  are  caused  partly  by  the 
atony,  partly  by  reflex  spasm  of  the  compressor  urethrae  muscle. 

Very  exceptionally  complete  retention  of  urine  is  an  early  symptom  of 
hypertrophy.  It  is  then  an  expression  of  acute  congestion  incident  to  excess, 
exposure  to  cold,  etc.  In  the  later  stage  of  the  affection  it  is  due  to  permanent 
overgrowth.  As  a  result  of  vesical  and  renal  retention  there  is  always  polyuria, 
the  urine  being  of  low  specific  gravity.  This  hypersecretion  of  urine  is  one  cause 
of  frequency,  and  this  fact  should  be  remembered  in  estimating  the  bladder- 
capacity  and  the  significance  of  frequent  urination. 

As  the  disease  progresses,  in  consequence  of  severe  straining,  hemorrhoids, 
rectal  prolapse,  or  abdominal  hernia  may  develop.  Ultimatel}^,  if  the  obstruc- 
tion is  untreated,  there  will  be  dilatation  of  the  ureters  and  kidney  pelves,  and 
in  infected  cases  the  development  of  pyelonephritis  and  uraemic  poisoning. 

Exceptionally  there  is  bleeding.  This  may  be  severe  and  spontaneous,  in 
which  case  there  is  usually  relief  of  symptoms.  It  is  commonly  due  to  instru- 
mentation.    Calculus  not  infrequently  develops. 

It  is  evident  that  the  symptoms  of  enlarged  prostate  are  those  of  obstruction 
to  the  passage  of  urine,  to  which  are  ordinarily  added  symptoms  of  inflammation. 
The  obstructive  sym.ptoms  are  comparatively  painless,  and  are  slowly  pro- 
gressive; they  ultimately  bring  about  changes  in  the  upper  urinary  tract,  which 
lead  to  increasing  renal  insufficiency.  Inflammation  converts  this  slow,  painless 
disease  into  one  that  is  extremely  painful,  is  often  rapid  in  its  course,  and  is 
immediately  threatening  to  life.  From  this  consideration  the  importance  of 
strict  cleanliness  in  dealing  with  cases  of  enlarged  prostate  is  evident. 

Diagnosis. — In  the  presence  of  the  symptoms  of  prostatic  obstruction  in  a 
man  over  fifty-five  years  of  age — i.e.,  a  feeble  stream  started  with  difficulty, 


SURGERY  OF  THE  PROSTATE  405 

frequent  urination,  most  marked  at  night,  and  a  feeling  as  though  the  bladder 
were  not  completely  emptied, — a  positive  diagnosis  may  be  made  by  direct 
examination. 

The  first  step  in  this  direction  consists  in  the  introduction  of  a  finger  into 
the  rectum. 

The  patient  standing  with  his  legs  apart  and  leaning  forward,  his  hands  upon 
a  table  or  chair,  the  index-finger  protected  by  a  cot  is  introduced  through  the 
sphincter,  and  an  effort  is  made  to  feel  the  base  of  the  prostate.  As  the  finger 
is  entered  more  deeply  the  lateral  outlines  of  the  gland  are  explored,  and  its 
density,  the  irregularities  of  its  surface,  finally  the  height  to  which  it  reaches, 
are  noted,  the  finger  being  carried  on  until  the  soft  bladder  can  be  felt  above 
the  upper  border  of  the  prostate.  In  these  subjects  bimanual  palpation  is 
distinctly  serviceable.  It  will  be  remembered  that  the  normal  prostate  is  about 
the  size  of  a  horse-chestnut,  is  often  cordate  in  shape,  with  the  base  upward 
towards  the  bladder,  is  not  very  sensitive  to  pressure,  and  can  be  clearly  out- 
lined by  rectal  palpation.    Above  it  the  bladder-wall  can  be  felt. 

The  next  step  in  direct  examination  consists  in  the  introduction  of  urethral 
instruments.  This  will  enable  the  surgeon  to  determine  the  extent  to  which  the 
prostatic  portion  of  the  canal  has  been  lengthened,  the  thickness  of  the  gland, 
the  presence  of  lateral  deviations,  the  position  and  extent  of  an  obstruction 
placed  at  the  neck  of  bladder,  and  the  amount  of  residual  urine. 

In  considering  the  advisability  of  the  passage  of  instruments  in  a  given  case, 
it  must  be  recognized  that  the  chronic  obstruction  reduces  the  normal  resist- 
ance of  the  bladder  and  kidneys  to  infection,  and  that  the  great  majority  of 
Ihose^hich  have  uninfected  urine  prior  to  the  passage  of  an  instrument  will 
become^ihfecIeicT  at  tTie"fifsr  passage  of  a  catheter,  and  if  not  at  the  first,  then 
at  a  comparatively  early  period  in  its  use,  and  this  in  spite  of  the  most  skilful 
manipulation  and  the  most  careful  asepsis;  and  this  infection  involves  not  only 
the  bladder,  but  the  ureters  and  renal  pelves  as  well.  Because  of  this,  the 
patients  who  come' to' the' surgeon"  with 'Hadders  already  infected  as  a  class  are 
more  easily  managed  than  those  who  come  with  sterile  urine,  for  their  tissues 
have  established  a  certain  tolerance  to  infection,  and  for  this  reason  they  stand 
instrumentation  better  and  run  a  smoother  course. 

It  is  therefore  proper  in  the  case  of  patients  with  urine  containing  pus  to 
proceed  without  hesitation  to  procure  such  information  as  seems  desirable  by 
means  of  careful  urethral  instrumentation;  but  in  the  case  of  patients  whose 
bladders  are  as  yet  uninfected  some  hesitation  may  be  felt,  and  the  decision 
made  on  the  intensity  of  the  symptoms  presented.  If  these  are  of  such  a  nature 
that  interference  is  evidently  demanded,  the  patient  requiring  either  operative 
treatment  or  the  institution  of  catheter  life,  then  it  is  wise  to  proceed  with  the 
examination,  using  all  possible  precautions  against  infection.  If,  however,  there 
are  obvious  reasons  why  neither  of  these  forms  of  treatment  should  be  instituted, 
it  is  the  wiser  course  to  forego  all  instrumentation. 

For  the  purpose  of  determining  the  extent  to  which  the  urethra  is  lengthened, 
a  soft  elbowed  catheter  is  employed.  Urethral  length  varies  so  greatly. in  indi- 
viduals that  it  is  impossible  to  establish  a  standard  which  will  apply  to  every 
case.    As  a  rule,  it  is  safe  to  conclude  that  if  the  catheter  has  to  be  passed  more 


406  GENITO-URINARY  SURGERY 

than  eight  and  one-half  inches  to  evacuate  the  urine  from  a  bladder  containing 
three  or  four  ounces,  the  prostate  is  enlarged.  A  more  accurate  way  of  arriving 
at  the  length  of  the  prostatic  urethra  is  to  determine  the  length  of  the  anterior 
urethra  by  passing  an  acorn-headed  bougie  to  the  anterior  layer  of  the  triangular 
ligament.  A  catheter  is  then  introduced  into  the  bladder  containing  but  a  few 
ounces,  and  when  urine  begins  to  flow  the  point  on  its  shaft  corresponding  to 
the  position  of  the  meatus  is  marked.  When  the  catheter  is  withdrawn,  measure- 
ments are  taken  from  this  point  to  the  end  of  the  eye.  Subtracting  the  anterior 
urethral  length  from  the  total  length,  the  remainder  represents  the  length  of 
the  prostatic  and  membranous  portions  of  the  canal;  three-quarters  of  an  inch 
can  be  allowed  for  the  membranous  urethra.  Should  the  prostatic  urethra  be 
found  over  one  and  three-quarter  inches  long,  the  diagnosis  of  enlargement  of 
the  prostate  is  reasonably  assured. 

Metal  instruments  are  employed  to  determine  the  presence  of  lateral  devia- 
tions of  the  prostatic  urethra,  the  thickness  of  the  enlarged  gland,  and  the  seat 
and  projection  of  growths  about  the  neck  of  the  bladder.  They  should  never 
be  grasped  tightly  when  they  are  introduced.  A  stone  searcher  when  it  can  be 
introduced  without  the  use  of  undue  force  is  best  adapted  to  the  purpose. 
Pressure  should  be  gentle,  and  so  directed  that  the  instrument  may  follow  any 
slight  irregularities  in  the  direction  of  the  prostatic  urethra.  It  will  often  happen 
that  before  the  instrument  can  be  made  to  enter  the  bladder  th'^  handle  must 
be  considerably  lateralized,  showing  deviation  of  the  urethra  to  one  side,  or 
when  the  middle  portion  of  the  prostate  is  enlarged  and  projects  upward  the 
handle  may  have  to  be  depressed  much  more  than  is  usually  the  case.  When 
the  instrument  has  entered  the  bladder,  palpation  against  its  shaft  through 
the  rectum  may  give  an  approximate  idea  of  the  antero-posterior  diameter 
of  the  gland.  The  beak  of  the  instrument  is  then  turned  in  all  directions,  and 
a  careful  exploration  is  made  for  stone,  since  this  is  a  frequent  complication  of 
prostatic  enlargement.  After  exploration  of  the  bladder  is  completed  the  instru- 
ment is  withdrawn  until  the  beak  lies  just  within  the  internal  vesical  sphincter. 
Then,  by  turning  it  from  side  to  side,  not  only  can  the  base  of  the  bladder  be 
explored,  but  polypoid  tumors,  which  sometimes  project  about  the  neck  of  the 
bladder,  can  be  distinctly  felt.  In  case  of  a  healthy  bladder  and  prostate,  the 
rotation  of  this  sound  when  its  beak  is  still  within  the  neck  of  the  bladder  is 
unattended  with  resistance.  If  there  is  marked  hypertrophy,  and  particularly 
if  the  middle  portion  of  the  prostate  is  affected,  jutting  back  into  the  bladder, 
the  beak  of  the  instrument  cannot  be  rotated  in  this  way,  but  will  encounter 
a  resistance  from  which  it  can  be  freed  only  by  greatly  depressing  the  handle. 
For  the  purpose  of  determining  by  instrumentation  which  lateral  lobe  is  enlarged, 
Mercier,  after  having  explored  the  bladder,  withdraws  the  instrument,  keeping 
its  shaft  as  nearly  horizontal  as  possible  as  it  traverses  the  prostatic  urethra.  The 
shaft  of  the  bougie  will  be  deflected  to  the  side  of  the  greatest  enlargement;  in 
cases  of  symmetrical  enlargement  there  will  be  no  deflection.  The  most  accurate 
method  of  determining  the  manner  and  extent  to  which  the  prostate  encroaches 
on  the  bladder  is  by  cystoscopy  (see  p.  47) . 

The  patency  of  the  urethra  and  the  encroachments  upon  its  calibre  by  pros- 
tatic outgrowths  are  best  ascertained  by  introducing  full  calibre  solid  steel  instru- 


SURGERY  OF  THE  PROSTATE  407 

ments,  or  silver  or  soft  English  catheters.  If  these  instruments  are  arrested 
at  a  point  more  than  seven  inches  from  the  meatus,  the  obstruction  is  in  the 
prostatic  urethra.  If  an  instrument  with  a  prostatic  curve  is  arrested  at  the 
same  point,  but  on  continued  pressure  passes  on  into  the  bladder,  often  with  a 
distinct  jump,  and  if  a  Mercier  elbowed  catheter  goes  in  without  difficulty,  the 
obstruction  is  probably  one  caused  by  upward  projection  of  the  urethral  floor, 
and  its  distance  from  the  meatus  can  be  measured  by  the  solid  sounds.  If  the 
moderately  stiff  Mercier  catheter  will  not  pass,  but  a  very  small  gum  catheter 
or  one  of  the  rat-tail  pattern  enters,  the  urethra  is  probably  deflected  to  one 
side  or  the  other.  If  all  instruments  enter  readily,  but  the  outward  flow  of 
urine  is  decidedly  interfered  with,  the  obstruction  is  valvular. 

The  amount  of  residual  urine  is  determined  by  introducing  a  catheter  after 
the  patient  has  attempted  to  empty  his  bladder,  drawing  off  what  remains. 
Normally  no  urine  should  flow  through  this  catheter,  or  at  most  a  few  drops. 
Measurements  of  the  urethral  length  can  advantageously  be  made  during  this 
portion  of  the  exploration. 

The  tonicity  of  the  bladder  is  estimated  by  the  force  with  which  the  urine  is 
propelled  through  the  catheter. 

Differential  Diagnosis. — The  differential  diagnosis  of  obstruction  from 
enlarged  prostate  must  be  made  from  that  due  to  stricture,  to  chronic  posterior 
urethritis,  to  chronic  prostatitis  with  contracture  of  the  internal  vesical  sphincter, 
to  calculus,  to  bladder-tumors,  to  vesical  atony,  and  to  paralysis. 

In  stricture  there  is  a  small  stream  which  often  has  considerable  force;  in 
prostatic  obstruction  the  stream  may  be  large,  but  is  without  its  normal  parabolic 
curve.  Stricture,  as  a  rule,  attacks  young  men;  enlarged  prostates  are  chiefly 
observed  in  old  men.  Stricture  causes  obstruction  to  the  passage  of  the  instru- 
ments within  six  and  a  half  inches  of  the  meatus;  the  obstruction  of  enlarged 
prostate  is  more  than  seven  inches  from  the  meatus.  There  is  no  increase  in 
urethral  length  in  stricture;  this  is  nearly  always  present  in  enlarged  prostate. 

Chronic  posterior  urethritis  is  commonly  observed  in  young  and  middle-aged 
men,  and  is  often  a  sequel  to  gonorrhoea;  there  is  little  or  no  increase  in  the 
size  of  the  prostate,  by  either  rectal  or  urethral  examination ;  there  is  constantly 
a  small  quantity  of  pus  in  the  urine,  and  the  force  of  the  stream  is  not  markedly 
diminished,  although  there  may  be  trouble  in  starting  it  and  an  imperfect  cut- 
off.   There  is  no  residual  urine. 

Chronic  prostatitis  associated  with  contracture  of  the  internal  vesical  sphinc- 
ter is  especially  characterized  by  retention  of  urine,  slowly  but  persistently  pro- 
gressive and  rarely  absolute — no  prostatic  enlargement  is  found  either  by  rectal 
palpation  or  urethral  examination — the  urethral  length  may  be  shorter  than 
normal,  and  the  cystoscope  and  sound  fail  to  demonstrate  irregularities  about 
the  bladder  neck.  This  form  of  prostatitis  may  or  may  not  be  accompanied  by 
the  symptoms  of  chronic  posterior  urethritis.  If  obstruction  to  instrumentation 
is  detected  it  is  found  at  the  internal  vesical  sphincter. 

Vesical  calculus  is  most  painful,  and  causes  most  marked  frequency  of  urina- 
tion when  the  patient  is  up  and  about,  and  the  symptoms  are  markedly  alleviated 
b}^  rest  in  bed.  Usually  severe  pain  and  tenesmus,  especially  if  associated  with 
pus  and  blood  in  the  urine,  and  if  paroxysmally  persistent,  should  always  sug- 
gest the  presence  of  stone  in  the  bladder.     Rectal  examination  and  exploration 


408  GENITO-URINARY  SURGERY 

of  the  bladder  with  stone  searcher  or  cystoscope  should  at  once  estabhsh  the 
diagnosis. 

Intravesical  tumor  may  closely  simulate  the  symptomatology  of  enlarged 
prostate.  Hsematuria  is,  however,  pronounced,  and  becomes  progressively  more 
severe.  As  a  rule,  frequency  of  urination  is  greater  by  day  in  tumor  and  at 
night  in  prostatic  hypertrophy.  Rectal  and  cystoscopic  examinations  will  estab- 
lish the  diagnosis. 

The  diagnosis  of  hypertrophied  prostate  from  atony  or  paralysis  of  the 
bladder  is  dependent  upon  the  history  of  the  case  and  upon  exclusion  of  enlarge- 
ment of  the  prostate  by  rectal  and  urethral  examination. 

The  clinical  classification  of  cases  of  prostatic  enlargement  should  be  made 
from  the  standpoint  of  the  degree  of  urinary  obstruction  occasioned  by  the  gland 
and  the  presence  or  absence  of  vesical  infection. 

Retention  is  the  symptom  of  obstruction.  This  may  be  acute  or  chronic, 
partial  or  complete.  The  incomplete  chronic  retention  may  or  may  not  be 
accompanied  by  vesical  distention.  Any  of  these  forms  of  retention  may  be 
comphcated  by  infection. 

The  acute  complete  retention  is  usually  observed  in  men  who  have  exhibited 
symptoms  of  moderate  obstruction  and  is  due  to  sudden  congestion  of  the  pros- 
tate. In  most  of  these  cases  there  has  been  a  previous  long-standing  condition 
of  incomplete  retention  with  or  without  bladder  dilatation. 

Chronic  complete  retention  is  practically  always  accompanied  by  vesical 
dilatation.     In  this  condition  no  urine  is  passed  by  voluntary  effort. 

Chronic  incomplete  retention  implies  the  ability  partially  to  empty  the 
bladder,  a  residuum  being  left  which  may  not  greatly  increase  if  the  bladder- 
walls  become  thickened  by  muscular  overgrowth  or  inflammatory  infiltrate  and 
organization,  or  which  may  gradually  produce  enormous  distention,  the  over- 
flow then  passing  both  voluntarily  and  involuntarily. 

Retention,  if  progressive,  inevitably  results  in  vesical  atony  and  distention, 
and  ultimately  in  interstitial  nephritis  and  renal  insufficiency.  At  times  it  is 
accompanied  by  hemorrhage  from  the  dilated  veins  of  the  urethral  or  vesical 
mucosa,  exceptionally  spontaneous,  usually  provoked  by  instrumentation.  Cys- 
titis, though  usually  first  excited  by  catheterism,  m.ay  arise  independent  of  this, 
and  may  be  secondary  to  pyelitis  or  pyelonephritis.  Vesical  calculus  is  a 
common  sequel  of  cystitis  and  residual  urine,  and  epididymitis  is  a  common 
complication  of  catheterism  when  the  bladder  and  posterior  urethra  are  infected. 

Prognosis. — Men  of  over  sixty  years  commonly  enough  exhibit  a  symptom- 
complex  characterized  by  frequency  of  urination,  especially  at  night,  slowness 
in  starting  the  urinary  stream,  intermittence  and  lack  of  force  in  its  propulsion, 
and  dribbling  at  the  end.  On  rectal  examination  the  prostate  shows  the  mod- 
erate enlargement  common  at  this  time  of  life.  These  patients  can  hold  their 
water  comfortably  three  or  fqjir  hours;  if  a  residuum  be  sought  for,  usually  an 
undesirable  procedure,  either  none  or  at  most  a  few  ounces  will  be  found.  This 
condition  is  due  in  part  to  lack  of  detrusor  force,  in  part  to  vasomotor  insta- 
■  bility  and  muscular  incoordination,  and  may  be  so  slowly  progressive  that 
treatment  other  than  hygienic  and  circulatory  is  not  indicated. 

When,  however,  the  bladder  becomes  permanently  distended,  or  when  cystitis 


SURGERY  OF  THE  PROSTATE  409 

develops  either  with  or  without  distention  in  the  presence  of  residuum,  so  that 
frequency  and  urgency  are  harassing  by  night  and  crippling  by  day,  or  when 
there  is  the  incontinence  of  overflow,  in  the  absence  of  surgical  intervention 
death  may  be  predicted  in  months  or  at  most  in  a  few  years,  usually  from 
renal  insufficiency  incident  to  back  pressure  and  ascending  infection. 

TREATMENT  OF  HYPERTROPHY  OF  THE  PROSTATE 

Palliative  Treatment. — This  has  for  its  end  the  regulation  of  pelvic  cir- 
culation in  such  wise  that  both  active  and  passive  congestion,  with  their  incident, 
increased  obstruction  from  swelling  and  spasm,  may  be  avoided.    This  implies: 

1.  Careful  medicinal,  dietetic,  and  mechanohydropathic  regulation  of  the 
cardiovascular  system. 

2.  The  maintenance  of  a  bland  condition  of  the  urine  by  the  drinking  of 
much  water,  but  always  short  of  interfering  with  digestion. 

3.  At  least  once  daily  a  bowel  movement,  secured  by  abdominal  massage, 
deep  breathing,  paraffin  oil,  and  copious  enemas  of  hot  normal  saline  solution; 
in  case  of  need,  senna,  cascara,  and  colocynth  are  the  drugs  of  choice;  always 
the  laxative  which  the  individual  has  found  best  suited  to  his  needs  is  to  be 
employed. 

Surfeit,  and  even  the  moderate  eating  of  food  which  is  known  to  disagree, 
alcohol  in  excess,  surface  chilling,  cold  wet  feet,  prolonged  sexual  excitement, 
withstanding  the  desire  to  empty  the  bladder,  constipation,  over-fatigue  (either 
physical  or  mental) — these  are  conditions  which  distinctly  aggravate  prostatic 
congestion  and  favor  attacks  of  acute  retention. 

Horseback  and  bicycle  riding  are  helpful  to  some  patients,  hurtful  to  others. 

Night  frequency  can  be  lessened  by  a  hot  bath  on  retiring,  the  bladder  being 
emptied  at  this  time  by  a  series  of  easy  efforts.  In  the  morning  also  the  urine 
is  to  be  passed  in  a  similar  manner,  the  patient  being  instructed  to  pass  without 
straining  as  much  as  practicable  on  rising;  thereafter  again  when  through  exer- 
cising and  "  breathing;  "  again  after  shaving;  again  after  bathing;  again  when 
half  dressed;  and  again  when  completely  dressed. 

Medicinal  Treatment. — Since  many  cases  of  partial  retention  are  due  to 
venous  engorgement,  drugs  which  influence  the  underlying  cardiovascular  con- 
dition are  of  major  importance.  A  too  acid  or  too  alkaline  condition  of  the 
urine  may  be  temporarily  remedied  by  full  doses  of  sodium  bicarbonate  or  the 
acid  phosphate  of  sodium.  The  sphincteric  spasm  is  at  times  influenced  favor- 
ably by  hyoscyamine  sulphate  (gr.  ^/oon  twice  daily).  Saw  palmetto  and  santyl 
have  at  times  a  distinctly  beneficial  effect  upon  the  vesical  tonus. 

Intermittent  Dilatation. — A  patient  who  presents  the  symptoms  of  a  pros- 
tato-vesical  congestion  of  the  early  stages  of  hypertrophy  who  is  disturbed  once 
or  twice  at  night,  who  has  an  enlargement  of  moderate  density,  appreciable 
through  the  rectum,  but  not  offering  much  resistance  to  the  introduction  of  an 
ordinary  catheter,  and  who  has  but  little  residual  urine,  may  derive  benefit 
from  the  systematic  introduction  of  full-sized  steel  sounds,  or  the  use  of  a 
Kollman  dilator.  The  largest  steel  sound  which  the  membranous  urethra  will 
permit  to  pass  is  introduced  every  fifth  day,  and  is  allowed  to  remain  in  place 
for  ten  to  fifteen  minutes.    Preliminary  irrigation  of  the  urethra,  careful  sterili- 


410  GENITO-URINARY  SURGERY 

zation  of  the  instrument,  and  gentleness  in  its  introduction  lessen  the  danger  of 
posterior  urethritis,  cystitis,  and  ascending  infection,  but  cannot  guard  com- 
pletely against  them.  Since  the  membranous  urethra  will  not  admit  an  instru- 
ment sufficiently  large  to  stretch  the  internal  sphincter,  it  is  probable  that  the 
beneficial  effect  of  this  treatment  is  attributable  to  the  traumatic  inflammation 
excited  thereby. 

Rectal  Injections. — These  may  be  hot  or  cold,  as  the  patient  prefers,  and 
may  be  of  normal  saline  solution  when  ordinary  water  congests  and  irritates 
the  mucous  membrane  of  the  rectum.  The  stream  of  water  should  be  thrown 
forcibty  upward  and  forward  directly  against  the  prostate,  and  the  injecting- 
pipe  should  be  provided  with  openings  through  which  the  liquid  escapes  at  once 
without  distending  the  rectum. 

Massage,  particularly  vibratory  massage,  is  useful,  not  so  much  because  it 
causes  shrinking  of  the  prostate  as  because  of  its  tonic  effect  upon  the  walls 
of  the  blood-vessels,  thus  diminishing  congestion  and  rendering  the  circulation 
more  normal.  Properly  it  is  not  painful,  and  leaves  the  patient  with  a  sense 
of  added  comfort.  It  should  be  repeated  at  two-  or  three-day  intervals.  It  is 
particularly  serviceable  in  the  treatment  of  prostatism  associated  with  small 
prostates. 

X-Ray  and  Radium. — Some  cases  of  prostatic  enlargement  have  been  cured 
by  radium  applied  through  the  rectum,  through  the  urethra,  or  through  a  supra- 
pubic opening.  Neither  the  dosage  nor  the  form  of  enlargement  most  amenable 
to  the  treatment  has  been  fully  determined.  The  X-ray  promises  less  than  does 
radium. 

Catheterism. — The  catheter  is  used  for  the  relief  of  retention.  It  may  be 
required  occasionally,  as  in  cases  of  acute  retention,  habitually,  as  in  cases  of 
chronic  retention  with  or  without  distention,  or  continuously,  as  in  cases  of 
infection  with  systemic  absorption.  In  using  a  catheter  for  the  relief  of  retention 
that  instrument  should  be  selected  which  enters  the  bladder  most  easily,  usually 
an  elbowed  soft  rubber  catheter.  Each  introduction  should  be  preceded  by 
urethral  irrigation,  preferably  with  protargol  solution  1  to  2000,  since  the  anterior 
urethra  is  always  infected.  (For  details  of  Catheterism,  see  p.  70.)  All  forms 
of  urinary  retention  caused  by  enlarged  prostate  are  amenable  to  treatment  by 
regular  cleanly  catheterization,  and  in  those  cases  characterized  by  acute  com- 
plete retention  this  treatment  may  be  curative,  at  least  to  such  an  extent  that 
the  patient  is  again  able  to  void  his  urine  and  is  troubled  only  by  frequency, 
some  loss  of  power  in  the  stream,  and  a  residuum  too  insignificant  to  produce 
troublesome  symptoms.  In  all  other  forms  of  progressive  retention,  either  with 
or  without  infection,  the  catheter  may  serve  a  useful  purpose  in  saving  the 
bladder  and  kidneys  from  the  inevitable  effects  of  unrelieved  and  steadily  in- 
creasing back  pressure. 

It  should  be  used  for  the  relief  of  retention  as  often  as  is  needful  to  prevent 
the  bladder  from  containing  more  than  eight  ounces  at  a  time,  and  should 
be  supplemented  by  mild  antiseptic  urethral  and  vesical  irrigations.  Vesical 
irritability  associated  with  inability  to  pass  any  water  at  all,  or  at  most  a  few 
drops,  may  require  the  use  of  the  catheter  much  more  frequently,  this  being 
particularly  the  case  when  there  is  complete  retention  in  a  non-distended 
infected  bladder. 


SURGERY.  OF  THE  PROSTATE  •    411 

When,  because  of  back  pressure  or  infection,  or  a  combination  of  these  con- 
ditions, renal  insufficiency  develops,  characterized  by  gastro-intestinal  break- 
down, hebetude  or  somnolence,  and  other  ursemic  manifestations,  or  by  septic 
fever,  continuous  catheterization  is  peculiarly  serviceable.  A  catheter  con- 
tinuously worn  in  the  urethra  causes  a  urethritis  which  in  the  course  of  months 
practically  destroys  the  mucosa.  By  withdrawing  the  instrument  twice  daily 
while  a  cleansing  irrigating  fluid  flows  through  it,  and  by  changing  the  instru- 
ment before  it  becomes  roughened  by  urinary  deposits,  such  an  instrument  may 
be  worn  for  years,  the  patient  keeping  it  corked  until  such  time  as  he  cares 
to  urinate. 

The  mouth  administration  of  urinary  antiseptics,  particularly  hexamethy- 
lenamine  and  salol,  is  specially  indicated  before  an  instrument  is  passed  into 
a  non-infected  bladder  and  for  two  or  three  days  thereafter;  the  long-continued 
administration  of  these  drugs  is  undesirable.  Though  catheterization  usually 
impHes  infection,  this  is  not  always  the  case.  Some  individuals  seem  immune 
even  when  filthy  instruments  are  carelessly  used  with  great  frequency. 

The  complications  incident  to  catheterization  are:  difficulty  in  the  introduc- 
tion, either  mechanical  or  incident  to  pain,  in  the  latter  case  greatly  relieved  by 
preliminary  instillations  of  four  per  cent,  eucaine  solution;  urethritis,  prevented 
by  irrigation  each  time  the  instrument  is  passed;  epididymitis,  prevented,  if 
recurring,  by  vasectomy;  hemorrhage,  avoided  by  the  selection  of  the  proper 
instrument  and  extreme  gentleness;  and  infection  at  time  prevented  by  anti- 
septic irrigations  and  cleanliness. 

Operative  Treatment 

As  a  rule,  when  habitual  use  of  the  catheter  is  required,  the  patient's  best 
interests  will  be  consulted  by  advising  operation,  the  expectation  of  life  being 
greater  with  operation  than  with  catheterism,  while  the  physical  comfort  after 
operative  treatment,  as  compared  with  the  continual  annoyance  of  catheterism, 
is  vastly  to  be  preferred.    This  may  take  the  form  of — 

1.  Over-dilatation  of  the  internal  vesical  sphincter,  applicable  to  cases  of 
small  hard  prostates,  complicated  by  sclerosis  of  the  sphincter. 

2.  Prostatotomy,  or  incision  of  the  internal  vesical  sphincter  and  prostate, 
particularly  applicable  in  the  small  sclerosed  prostate. 

3.  Prostatectomy,  or  enucleation  of  the  prostate  gland  or  the  adenomata 
which  cause  the  obstruction,  applicable  to  all  cases  of  prostatic  enlargement 
causing  sufficient  obstruction  to  engender  harassing  symptoms  and  threaten 
renal  integrity. 

4.  Castration  or  vasectomy. 

5.  Cystostomy,  applicable  to  cases  of  inveterate  cystitis,  in  which  the  sys- 
temic condition  is  such  as  to  make  unjustifiable  the  more  radical  procedure. 

Preoperative  Examination  and  Preparation. — The  first  examination  deals 
with  the  exclusion  of  tabes,  by  testing  the  patient's  station,  pupil  reflex,  and 
knee  jerks,  the  estimation  of  cardiovascular  competence  by  observing  the  effect 
of  exercise  upon  the  heart  action,  the  respiration,  and  the  peripheral  circulation, 
and  consideration  of  the  question  of  renal  adequacy  as  suggested  by  the  mental 
vigor,  interest  in  life,  appetite,  and  maintenance  of  normal  weight  and  endurance. 


412  GENITO-URINARY  SURGERY 

The  question  of  renal  competence  being  perhaps  the  major  one  in  deciding  for 
or  against  radical  operation  is  further  decided  by  the  quantity  of  urine  passed 
in  twenty-four  hours,  its  specific  gravity,  and  the  presence  or  absence  of  abnormal 
content,  but  particularly  by  the  various  tests  of  elimination,  especially  that 
employing  phenolsulphonephthalein  (see  p.  21).  The  presence  or  absence  of 
sugar  is  of  itself  of  little  moment. 

Given  a  slow  and  low  phthalein  output,  associated  with  weakness,  lethargy, 
loss  of  weight,  and  loss  of  appetite,  the  dominant  question  is  as  to  whether  the 
kidneys  have  been  irretrievably  damaged  by  long-continued  back  pressure,  or 
are  capable  of  regaining  all  or  a  part  of  their  lost  power  should  the  back  pressure 
be  removed.  The  question  is  best  settled  by  instituting  continuous  catheteriza- 
tion, or,  should  this  prove  harassingly  painful,  by  suprapubic  drainage  effected 
under  local  anaesthesia. 

The  first  effect  of  removing  the  back  pressure  on  the  kidneys  produced  by 
any  considerable  quantity  of  residual  urine  is  fourfold:  a  reduction  in  the 
blood-pressure,  urinary  output,  and  functional  power,  as  indicated  by  their 
ability  to  eliminate  such  test  substances  as  phenolsulphonephthalein,  and  an 
increase  in  the  quantity  of  albumin,  or  an  appearance  of  this  element,  all 
incident  to  renal  congestion.  To  these  must  be  added,  in  case  the  bladder  has 
previously  been  free  from  infection,  in  the  great  majority  of  cases  the  develop- 
ment of  an  acute  cystitis.  The  tax  of  these  factors  on  the  vital  reserve  of  a 
patient  already  past  the  prime  of  life  is  heavy,  often  all  that  he  will  bear.  It 
would  therefore  seem  the  wiser  course  not  to  add  at  this  time  the  shock  of 
general  anaesthesia  and  prostatectomy,  but  to  delay  this  operation  till  the 
system  has  had  an  opportunity  to  effect  a  readjustment.  This  may  take  place 
in  the  course  of  a  few  days,  or  not  till  after  the  lapse  of  many  weeks  or  months; 
in  some  cases  it  may  never  take  place  to  an  extent  to  warrant  the  performance 
of  a  radical  operation,  in  which  event  the  patient  should  content  himself  with 
permanent  suprapubic  drainage  or  catheterism. 

Stretching  of  the  Internal  Vesical  Sphincter. — This  is  indicated  in 
those  cases  of  prostatism  without  prostatic  enlargement.  The  obstruction  to  the 
urinary  flow  is  here  due  to  a  sclerosed  condition  of  the  internal  vesical  sphincter, 
a  muscle  which  in  its  normal  state  relaxes  when  the  bladder  contains  three  or 
four  ounces  of  urine.  This  sphincter  should  admit  the  index-finger,  but  when. 
as  a  consequence  of  chronic  prostatitis  or  inflammation  about  the  vesical  neck, 
it  undergoes  probably  first  hypertrophy  and  afterward  fibroid  degeneration,  it 
forms  a  narrow  hard  ring  into  which  the  tip  of  the  little  finger  can  be  passed 
only  with  difficulty,  though  it  may  admit  a  28  sound  passed  through  the  urethra 
with  only  a  slight  sense  of  resistance. 

This  operation  may  be  accomplished  under  nitrous  oxide  by  means  of  a 
dilating  instrument  which  we  have  had  constructed,  especially  for  this  purpose, 
the  extreme  calibre  of  which  is  seventy-five  millimetres.  Stretching  to  forty-five, 
the  extreme  calibre  of  the  usual  prostatic  dilator,  is  inadequate. 

In  employing  this  treatment  the  urethra  and  bladder  are  first  flushed  with 
1  to  2000  protargol  solution.  The  distance  from  the  meatus  to  the  internal 
vesical  sphincter  is  carefully  measured  and  the  instrument  is  introduced  so 
that  its  dilating  part  lies  exactly  within  the  grip  of  this  muscle.     Its  position 


SURGERY  OF  THE  PROSTATE  413 

can  be  further  assured  by  the  finger  of  an  assistant  in  the  rectum.  The  patient 
is  then  given  nitrous  oxide  and  the  screw  in  the  handle  is  rapidly  turned  until 
the  dilating  part  reaches  its  full  calibre.  Excepting  for  the  use  of  a  bland  diet 
and  urinary  antiseptics  by  the  mouth,  there  is  no  after-treatment. 

Prostatotomy. — By  this  term  is  meant  incision  through  the  internal  vesical 
sphincter  and  into  the  substance  of  the  prostate.  It  may  be  made  either  with, 
the  knife,  with  the  prostatic  punch  (Young's),  or  with  the  galvano-cautery 
instrument,  through  a  perineal  incision  or  through  the  urethra  (Bottini's  opera- 
tion). Each  has  for  its  end  the  removal  of  obstruction,  by  direct  division  in 
the  first  two  instances,  and  by  division  supplemented  by  extensive  sloughing 
in  the  last.  All  are  especially  applicable  to  small  hard  prostates  complicated 
by  retention  and  probably  by  sclerosis  and  contracture  of  the  internal  vesical 
sphincter,  though  the  advocates  of  the  Bottini  operation  claim  for  its  proper 
application  usefulness  in  nearly  all  forms  and  degrees  of  prostatic  enlargement. 

Perineal  prostatotomy  performed  by  the  knife  is  useful  in  providing 
an  efficient  route  for  permanent  drainage  of  the  bladder,  this  procedure  being 
especially  indicated  in  those  conditions  of  cystitis  so  pronounced  that  per- 
manent catheterization  is  either  unbearable  or  inefficient,  and  associated  with  a 
contracted,  rigid,  and  inflamed  bladder  too  small  to  be  readily  drained  by  the 
formation  of  a  suprapubic  fistula. 

Perineal  prostatotomy  can  be  performed  under  local  anaesthesia;  it  is, 
however,  better  to  employ  nitrous  oxide,  since  not  more  than  one  or  two 
minutes  are  required  for  the  comipletion  of  the  operation. 

After  preliminary  antiseptic  irrigation  of  the  bladder,  a  grooved  staff  is 
passed,  and  upon  this,  by  an  inch  long  incision  passing,  through  the  perineal 
centre,  the  membranous  urethra  is  opened.  A  probe-pointed  knife  engaging  in 
the  groove  of  the  staff,  the  blade  is  passed  into  the  bladder  and  then  withdrawn, 
cutting  forward  and  backward  through  the  internal  sphincter  and  into  the  sub- 
stance of  the  prostatic  commissure.  The  finger  should  then  be  passed  along 
the  staff  and  the  latter  withdrawn.  Thereupon  the  interior  of  the  bladder  may 
be  palpated.  The  vesical  neck  should  be  further  dilated  to  at  least  74  F.  This 
may  be  accomplished  by  Spencer  Wells  forceps  or  a  uterine  dilator.  A  drainage- 
tube  fully  the  size  of  the  little  finger  and  rigid  should  be  so  secured  that  its 
inner  opening  is  just  within  the  bladder,  and  to  this  tube  should  be  connected 
a  urinal  placed  at  a  level  sufficiently  low  to  drain  the  bladder.  When  it  is 
intended  to  establish  a  permanent  fistula,  Watson's  tube  of  hard  rubber  and 
designed  especially  for  this  operation  will  be  found  efficient.  When  the  drainage 
is  meant  to  be  temporary,  a  large  size  soft  rubber  catheter  (30  F.)  will  be 
found  serviceable.  Exceptionally,  hemorrhage  is  so  severe  as  to  require  packing. 
The  bladder  is  irrigated  at  least  twice  daily  with  silver  solution.  The  patient 
need  not  be  kept  in  bed  for  more  than  a  day  unless  this  be  indicated  by  his 
general  condition. 

A  perineal  fistula  is  less  desirable  than  one  placed  suprapubicly,  and  should  be 
formed  as  a  permanent  palliative  measure  only  when  the  latter  is  impracticable. 

"  Prostatic  Punch  "  Operation. — This  is  performed  by  means  of  a  special 
instrument,  such  as  that  designed  by  Young,  consisting  of  a  tube  (see  B,  Fig. 
216)  with  a  deep  notch  near  its  angle  for  the  reception  of  the  prostatic  bar, 


414 


GENITO- URINARY  SURGERY 


SURGERY  OF  THE  PROSTATE 


415 


e^ 

^ 


into  which  the  knife-edged  tube  C  can  be  sHpped  for  the  purpose  of  removing 
whatever  is  engaged  in  the  notch.  Three  pieces  are  usually  removed,  the  tirst 
in  the  median  line,  the  second  and  third  at  the  sides  of  the  first.  The  operation 
may  be  performed  under  local  or  nitrous  oxide  anaesthesia.  The  hemorrhage 
following  the  operation  may  be  sufficient  to  require  the  use 
of  a  large  aspirating  tube  for  the  evacuation  of  the  clots. 

Galvanocautery  Prostatotomy  through  a  Perineal 
Opening. — Chetwood  has  suggested  galvanocautery  in- 
cision through  a  perineal  opening.  His  instrument  (Fig. 
217)  resembles  that  devised  by  Bottini,  but  the  blade  is 
drawn  out  by  a  direct  pull  to  a  stop-pin  which  is  set  at 
the  desired  point.  The  results  are  verified  by  digital  explora- 
tion. Moreover,  complications  may  be  more  readily  treated 
and  the  danger  of  urinary  extravasation  from  an  incision 
carried  into  the  membranous  urethra  is  entirely  obviated. 
The  thorough  exploration  allowed  by  the  perineal  opening 
enables  the  surgeon  to  proceed  at  once  to  a  complete  pros- 
tatectomy in  case  this  be  deemed  advisable. 

Bouffleur  has  modified  the  galvanocautery  operation  by 
performing  it  through  a  suprapubic  cystotomy  incision, 
using  the  actual  cautery  heated  to  white  heat.  Many  cases 
can  be  treated  efficiently  through  the  cystoscope  by  means 
of  the  Oudin  current  (see  p.  56). 

Prostatectomy. — Removal  of  the  gland  is  indicated  in 
all  cases  of  pronounced  enlargement  with  symptoms  of  pro- 
gressively increasing  urethral  obstruction,  when  the  general 
condition  of  the  patient  warrants  the  performance  of  the 
operation.  The  softer  and  larger  the  gland  the  easier  and 
safer,  as  a  rule,  is  the  operation.  Small  dense  fibroid 
prostates,  particularly  those  which  are  the  seat  of  chronic 
inflammation,  are  least  amenable  to  this  treatment,  the  diffi- 
culties of  removal  being  great  and  the  operative  sequelae 
being  frequently  unsatisfactory. 

The     gland    may    be   removed    through    a    suprapubic 
opening,    the    operation   being    conducted    mainly    by    the 
guidance  of  touch,  or  through  a  transverse  curved  perineal 
opening,  the  operation  being  directed  by  both  the  senses  of   gaiva^nocau~ry  pro°°atic 
touch  and  sight.  ^^"'°'- 

As  to  the  choice  of  operation,  it  is  apparent  that  by  either  route  the  great 
majority  of  prostates  can  be  removed.  The  small  sclerosed  prostate,  the  cap- 
sule of  which  is  densely  adherent  to  the  fibrous  sheath,  can  be  most  safely 
reached  and  enucleated  through  a  transverse  perineal  opening.  Soft  fibro- 
glandular  prostates  can  be  readily  and  safely  enucleated  by  either  method. 

In  general  terms,  when  the  enlargement  is  mainly  of  the  median  lobe,  when 
there  is  a  complicating  stone,  or  when  it  is  desirable  to  make  a  direct  inspection 
of  the  bladder  for  any  reason,  the  suprapubic  operation  is  to  be  preferred ;  when 


416  GENITO-URINARY  SURGERY 

the  prostate  is  relatively  small,  hard,  and  fibrous,  likely  to  be  adherent  on 
account  of  an  old  inflammatory  condition,  and  in  the  very  fat,  the  perineal  is 
the  operation  of  choice ;  the  removal  of  adenomatous  enlargements  of  the  lateral 
lobes  can  be  accomplished  easily  by  either  route.  In  selecting  the  type  of 
operation  the  experience .  of  the  individual  operator  should  receive  about  equal 
consideration  with  the  character  of  the  prostate.  For  the  surgeon  without  special 
knowledge  of  either  route,  the  suprapubic  is  the  easier  and  probably  the  safer. 

As  in  all  conditions  implying  impaired  renal  competence,  nitrous  oxide  is 
the  anaesthetic  of  choice;  thereafter  in  order  to  safely  follow  spinal  anaesthesia, 
ether,  and  chloroform. 

Suprapubic  Prostatectomy. — For  the  performance  of  the  transvesical  oper- 
ation the  patient  is  placed  upon  a  table  so  constructed  that  in  case  of  need  the 
Trendelenburg  position  can  be  easily  obtained,  his  bladder  irrigated  and  filled 
with  eight  to  twelve  ounces  of  protargol  solution  (1  to  2000),  and  a  median 
incision  made  from  the  pubis  upward  for  two  to  four  inches,  according  to 
the  size  of  the  prostate  and  the  thickness  of  the  patient's  abdominal  wall. 
Packing  the  peritoneum  upward  and  backward  with  gauze,  and  retracting  the 
recti  muscles,  a  clean  high  cut  is  made  through  the  prevesical  fat  to  the 
bladder-wall,  clamping  and  tying  veins  if  they  be  in  the  way.  An  incision 
is  then  made  into  the  bladder  at  a  point  as  near  the  vertex  of  the  organ  as 
possible  without  wounding  the  peritoneum,  as  the  healing  is  more  prompt,  and 
the  danger  of  a  persistent  sinus  is  more  remote  when  a  high  incision  is  used. 
The  opening  in  the  bladder-wall  is  then  drawn  into  the  parietal  wound  by  means 
of  heavy  silk  threads  passed  with  a  curved  needle  through  the  whole  thickness 
of  the  bladder  on  each  side  of  the  vertical  cut. 

The  margins  of  the  bladder  wound  are  then  held  apart  and  a  digital  exami- 
nation made  to  determine  the  presence  or  absence  of  stones  or  neoplasms  and 
the  conformation  of  the  prostate. 

The  enucleation  of  the  prostate,  or  of  such  part  thereof  as  is  removed,  can 
usually  be  accomplished  with  one  or  two  fingers  without  the  aid  of  instruments, 
though  sometimes  it  is  necessary  to  use  a  long  pair  of  scissors  or  a  knife  to 
make  an  opening  in  the  mucosa,  or  to  free  a  dense  adhesion.  The  finger-nail  tears 
through  the  mucosa  in  the  anterior  wall  of  the  prostatic  urethra  where  it  opens 
into  the  bladder  as  when  started  here  it  is  easier  to  get  into  the  proper  line  of 
cleavage  than  when  the  intravesical  portion  of  the  gland  is  first  attacked  (Fig. 
218).  This  line  of  cleavage  lies  within  the  capsule  of  the  gland,  in  adenomatous 
prostates  between  the  hypertrophied  tissue  and  the  Compressed  but  otherwise 
unaltered  parenchyma  or  the  capsule.  When  extracapsular  removal  is  attempted, 
not  only  is  the  enucleation  difficult,  but  profuse  hemorrhage  is  encountered  from 
the  prostatic  venous  plexus.  Counter-pressure  by  one  or  two  fingers  in  the  rectum 
is  always  helpful,  usually  necessary,  for  complete,  safe,  and  expeditious  removal. 
Traction  upon  the  partly  enucleated  gland  by  means  of  forceps  is  often  helpful 
in  the  latter  part  of  the  dissection. 

The  removal  of  small  fibrous  prostates  by  the  suprapubic  route  is  often 
attended  by  extreme  difficulty,  and  must  often  be  accomplished  piecemeal. 

At  the  conclusion  of  the  operation  through  the  urethra  the  bladder  is  freed 


SURGERY  OF  THE  PROSTATE 


417 


of  blood  and  clots  by  irrigating  with  hot  solution,  and  if  there  be  no  excessive 
bleeding  the  bladder  incision  is  closed  tightly  about  a  large  drainage-tube,  the 
size  of  the  index-linger,  whose  fenestrated  end  projects  one  or  one  and  a  half 
inches  into  the  viscus.  Should  there  be  free  bleeding,  the  patient  should  be 
placed  in  the  Trendelenburg  position,  retractors  inserted,  the  interior  of  the 
bladder  dried,  and  gauze  packing  wet  with  adrenalin  solution  placed  in  the 
prostatic  bed,  the  end  being  brought  out  through  the  incision.  Should  this  fail 
to  control  the  hemorrhage,  the  packing  may  be  grasped  with  forceps,  the  handles 
of  which  project  through  the  suprapubic  incision,  and  pressed  upon  by  an 


Fig.    218. — Suprapubic   prostatectomy,   beginning   the   enucleation. 

Esmarch's  bandage  passed  about  the  body.  In  addition  to  the  bladder  drainage, 
a  cigarette  drain  should  always  be  placed  in  the  space  between  the  bladder  and 
the  pubis,  as  this  region  is  peculiarly  liable  to  infection. 

Postoperative  Treatment. — After  operation  the  patient  is  given  half  normal 
saline  solution  by  the  bowel,  a  pint  every  three  hours,  unless  it  becomes  pro- 
hibitively irksome.  The  suprapubic  drainage  is  led  by  rubber  tubing  of  full 
size  into  a  reservoir  placed  at  a  lower  level  than  the  bladder,  and  twice  daily 
by  means  of  a  short  urethral  nozzle  and  a  gravity  bag  the  bladder  is  flushed 
out  with  protargol  (1  to  4000).  The  large  tube  protects  in  a  measure  from 
blocking  by  clots;  should  this  occur  as  shown  by  vesical  distention,  pain  and 
27 


418 


GENITO-URINARY  SURGERY 


an  urgent,  continued,  and  distressing  desire  to  urinate,  the  tube  should  be 
freed  by  aspiration  and  irrigation.  The  patient  may  be  allowed  to  sit  up  as 
soon  as  he  feels  so  inclined,  and  may  usually  be  gotten  into  a  chair  on  the  third, 
fourth,  or  fifth  day.  The  cigarette  drain  should  come  out  on  the  second  day, 
and  on  the  fifth  to  the  seventh  day  the  bladder  tube  may  be  removed,  or  re- 
placed by  a  tube  or  catheter  of  smaller  size. 

Operative  Results. — rAfter  suprapubic  prostatectomy  a  certain  amount  of 
prostatic  tissue  usually  remains,  the  dissection  having  been  made  between  the 
adenomatous  overgrowth  and  the  compressed  prostatic  tissue.  Usually  the 
greater  part  of  the  prostatic  urethra  comes  away  with  the  growth,  but,  as  the 
canal  is  usually  broken  across  at  the  verumontanum  or  a  little  behind  this 
point,  the  patient  is  not  necessarily  rendered  sterile.  Nor  in  those  virile  previous 
to  operation  is  impotence  a  necessary  sequel. 


Fig.  219. — Various  perineal  incisions. 

The  suprapubic  opening  closes  in  from  ten  to  twenty  days,  and  the  patient 
regains  the  power  of  prompt,  forceful,  continuous  micturition,  with  almost 
normal  intervals  between  the  acts.  Many  patients  continue  to  exhibit  in- 
definitely slightly  cloudy  urine,  moderate  frequency  with  one  or  two  night 
risings,  and  a  small  residuum,  two  to  four  ounces.  They  nearly  all  show  an 
amazing  betterment  in  general  health,  as  though  youth  were  regained. 

Perineal  Prostatectomy. — The  prostate  has  been  approached  from  the 
perineum  by  two  routes:  through  median  incisions  and  through  semilunar  or 
inverted  "  V  "  incisions. 

Median  Perineal  Route. — By  this  method  an  incision  is  made  in  the  mem- 
branous urethra  through  which  the  finger  is  introduced  into  the  prostatic  por- 
tion. Such  portions  of  the  prostate,  usually  adenomatous  masses,  as  can  be 
enucleated  are  freed  with  the  finger  and  withdrawn  with  forceps,  and  the 
operation  is  concluded  by  putting  a  gauze  drain  in  the  prostatic  bed. 

The  operation  is  performed  entirely  by  the  sense  of  touch,  in  an  inadequate 
space,  is  accompanied  by  great  trauma  to  the  urethra,  and  is  applicable  only 
to  easily  enucleable  enlargements  of  moderate  size. 


SURGERY  OF  THE  PROSTATE 


419 


Transverse  Perineal  Route. — This  is  the  method  usually  followed  in  doing 
the  perineal  operation.  It  is  the  one  used  in  his  conservative  perineal  pros- 
tatectomy by  Young,  the  foremost  advocate  of  the  perineal  route.  The  method 
of  performing  this  operation  is  as  follows: 

A  grooved  staff — Ferguson's  is  the  best — is  introduced  into  the  urethra, 
and  the  patient  is  placed  in  the  exaggerated  lithotomy  position,  the  pelvis 
being  raised  from  the  table  either  by  means  of  Halsted's  perineal  board  or  a 
sand-bag,  the  thighs  being  flexed  on  the  abdomen,  so  that  the  perineum  is 
nearly  parallel  with  the  floor.  The  skin  and  superficial  fascia  are  incised, 
either  by  a  semilunar  cut  or  by  an  inverted  ''  V  "  incision  (see  Fig.  219),  the 
anterior  portion  of  the  exposed  area  lying  over  the  bulb,  while  the  posterior 
extremities  of  the  incision  are  on  a  level  with  the  anterior,  margin  of  the  anus. 


Fig.    220. — Showing  bifid  retractor,   exposing  and  making  tension  on  the 
central  tendon.     (Keen's  Surgery,     Courtesy  W.  B.  Saunders  Co.) 

By  blunt  dissection  a  space  is  now  opened  on  each  side  of  the  central  tendon 
of  the  perineum,  the  transversus  perinei  being  pushed  forward.  A  bifid  retractor 
is  inserted  (Fig.  220),  and,  close  to  the  bulb,  the  central  tendon  and  the  recto- 
urethralis  muscle  are  divided,  great  care  being  exercised  not  to  cut  into  the 
rectum,  which  is  drawn  forward  by  the  latter  structure.  The  levator  ani 
muscles  thus  exposed  are  separated  in  the  median  line  and  a  broad  retractor 
inserted,  bringing  the  posterior  surface  of  the  prostate  into  view.  The  next 
step  is  to  incise  the  membranous  urethra  on  the  staff,  and  to  insert  the  prostatic 
tractor  into  the  bladder.  The  insertion  of  this  instrument  (see  Figs.  221,  222, 
and  223)  is  greatly  facilitated  if  the  urethral  walls,  including  the  mucosa,  are 
caught  with  sutures  or  forceps  as  soon  as  the  incision  is  made.  On  account 
of  its  abrupt  curve  the  tractor  is  not  always  easy  of  introduction;   sometimes 


420 


GENITO-URINARY  SURGERY 


this  is  most  easily  accomplished  by  starting  with  the  handle  pointing  toward 
the  floor,  and  later  rotating  it  through  an  arc  of  180  degrees.    After  insertion 

r 


Fig.  221. — Opening  of  urethra  on  sound,  preparatory  to  introduction  of 

tractor.     (Young.) 


Fig.  222. — Young's  prostatic  tractor.     Closed. 
Fig.  223. — Young's  prostatic  tractor.     Opened. 


the  blades  are  opened  so  that  accidental  withdrawal  is  impossible;  by  traction 
upon  it  the  prostate  can  be  drawn  downward  into  the  wound  very  substantially. 


SURGERY  OF  THE  PROSTATE 


421 


The  whole  posterior  surface  of  the  prostate  is  now  exposed  bluntly  after 
incision  of  the  posterior  layer  of  Denonvilliers'  fascia,  the  exposure  being  made 
more  complete  by  the  insertion  of  narrow  lateral  retractors. 

To  give  access  to  the  lateral  lobes,  two  incisions,  1.5  cm.  deep,  are  made 
in  the  posterior  surface  of  the  organ  for  nearly  its  whole  length,  the  incisions 

1 


Fig.  224. — Tractor  in  position,  blades  separated,  prostate  pulled 
down,  posterior  surface  exposed.  Incisions  in  capsule  on  each  side  of 
ejaculatory  ducts.     (Voung.) 

being  about  1.8  cm.  apart  above  and  1.5  cm.  below  (Fig.  224).  The  tissue 
between  these  incisions  contains  the  prostatic  urethra  and  the  ejaculatory  ducts, 
and  is  therefore  not  to  be  removed.  The  enucleation  of  the  lateral  lobes  is 
started  by  inserting  a  blunt  dissector  beneath  the  capsule  to  the  outer  side  of  one 
of  the  incisions  (Fig.  225),  and  continued  with  dissector,  curved  scissors,  or 
finger,  as  is  found  most  convenient,  the  tractor  being  used  to  steady  the  prostate 
by  making  counter-pressure  on  its  vesical  surface.    Firm  adhesions  to  the  cap- 


422 


GENITO-URINARY  SURGERY 


Fig.  225. — External  enucleation  begun.     (Young.) 


I ^, 

Fig.  226. — ^Enucleation  of  lobes.    Forceps  in  position.     (Young.) 


SURGERY  OF  THE  PROSTATE 


423 


sule,  requiring  division  with  scissors,  are  usually  found  at  the  apex.  After  the 
lobes  have  been  partially  freed  the  application  of  forceps  is  of  great  assistance 
(Fig.  226). 

After  the  lateral  lobes  have  been  removed,  if  a  median  lobe  exists  this  is 
engaged  by  one  of  the  blades  of  the  tractor  and  pushed  to  one  side  or.  the 
other  (Figs.  227  and  228).  Median  bars  are  best  delivered  by  transfixing 
them  with  a  sharp  hook,  passed  in  through  one  of  the  lateral  cavities.  In 
the  case  of  either  median  lobes  or  bars  the  dissections  must  be  made  from  the 
ejaculatory  ducts  lying  behind  and  from  the  vesical  mucosa  in  front.  The 
operation  is  concluded  with  a  careful  digital  exploration  by  means  of  the  finger 
and'  tractor  to  see  that  no  enlargement  has  been  overlooked.  This  exploration 
should  include  the  insertion  of  the  finger  into  the  bladder  through  the  urethra, 
the  tractor  having  been   removed  after  securing  the  urethral  walls  that   the 


Fig.  227. — Delivery  of  a  small  median  portion  into  lateral  cavity 
by  the  use  of  finger  instead  of  tractor.     (Young.) 

proper  channel  may  be  easily  found.  This  examination  determines,  first,  the 
condition  of  the  vesical  neck,  whether  or  not  there  is  an}'  contracture,  and_. 
secondly,  whether  stones  exist  in  the  bladder,  if  this  fact  has  not  been  already 
ascertained  by  means  of  the  cystoscope.  Should  there  still  be  contracture  of 
the  neck,  this  must  be  thoroughly  stretched  by  means  of  heavy  forceps. 
Calculi  may  be  removed  either  through  the  urethra,  if  this  is  sufficiently  large, 
or  by  incising  one  of  its  walls  if  more  room  is  required  (Fig.  229). 

The  lateral  cavities  should  be  packed  with  gauze  and  the  bladder  drained  by 
means  of  a  large  tube  (double  if  continuous  irrigation  is  to  be  used)  (Fig.  230;. 
brought  out  through  the  anterior  portion  of  the  w^ound.  Behind  the  gauze  and 
tube  drains,  so  as  to  protect  the  rectum  from  pressure,  the  levator  ani  muscles 
are  approximated  with  a  single  catgut  suture.  The  skin  wound  is  closed  with 
interrupted  or  continuous  sutures  of  silkworm  gut  or  silk. 

Postoperative  Treatment. — The  drainage-tube  is  connected  with  a  reservoir 


424 


GENITO-URINARY  SURGERY 


placed  at  a  lower  level  than  the  bladder ;  through  the  tube  the  bladder  is  washed 
twice  a  day  with  protargol  (1  to  4000).  Blocking  of  the  tube  by  clots  is 
relieved  by  aspiration,  or  by  removal  and  replacement  of  the  tube. 

At  the  end  of  twenty-four  hours  the  gauze  packing  is  removed,  and  a  few 
hours  later  the  tube  is  withdrawn  from  the  bladder.    The  patient  should  now 


Fig.    228. — Delivery    of    median    portion    into    lateral    cavity. 
(Young.) 

be  urged  to  sit  up  in  bed  for  a  brief  period;  he  should  be  gotten  into  a  chair 
on  the  second  to  the  fourth  day,  and  may  walk  about  as  soon  as  he  feels  so 
inclined. 

Partial  reestablishment  of  the  normal  urinary  channel  often  takes  place  as 
soon  as  the  drainage-tube  is  removed;  the  average  time  for  the  closure  of  the 
fistula  is  two  to  three  weeks. 


SURGERY  OF  THE  PROSTATE 


425 


Fig.  229.  —  Division  of  lateral  wall  of  urethra  to  allow 
extraction  of  large  calculus  through  lateral  cavity. 
(Young.) 


Fig.  230. — Manner  of  introduction  of  double  tube  drain  into  bladder  and  packing  into  bed 
of  enucleated  prostate  in  perineal  prostatectomy. 


426  GENITO-URINARY  SURGERY 

The  Results  of  Prostatectomy. — The  removal  of  the  prostate,  if  skilfully 
conducted  in  properly  selected  cases,  usually  affords  a  permanent  cure  of  urinary 
'retention,  and,  moreover,  produces  a  peculiarly  regenerating  effect  upon  the 
patients  so  treated. 

The  mortality  incident  to  prostatectomy  varies  with  the  care  used  in  the  selec- 
tion and  preparation  of  cases,  with  the  skill  of  the  operator,  with  the  type  of 
operation,  and  with  the  care  used  in  the  after-treatment.  The  need  for  care  in 
the.  preliminary  examination  and  pre-operative  treatment  of  these  patients  has 
already  been  dwelt  upon.  That  for  the  best  performance  of  an  operation  of 
the  severity  of  prostatectomy  the  judgment  and  skill  of  an  experienced  operator 
are  of  advantage  needs  no  argument.  The  perineal  operation  seems  to  have 
a  slightly  lower  mortality  than  the  suprapubic,  so  far  as  can  be  judged  from 
pubHshed  statistics,  possibly  because  of  better  drainage  of  the  bladder,  more 
probable  because  it  is  the  custom  to  get  these  patients  out  of  bed  at  an  earlier 
date.  On  the  other  hand,  injury  to  the  rectum,  incontinence  of  urine,  im- 
potence, and  urinary  fistula  are  more  apt  to  follow  the  perineal  than  the 
transvesical  procedure. 

The  postoperative  care  is  a  factor  of  great  import.  Water  by  mouth  and 
rectum,  adequate  vesical  drainage  {i.e.,  tubes  which  constantly  work),  relief 
from  wearing  pain  by  morphine,  mild  antiseptic  irrigation  twice  a  day,  deep 
breathing  and  light  surface  massage,  changes  of  posture,  the  avoidance  of  food 
till  the  patient  is  ready  for  it,  easy  emptying  of  the  bowel  on  the  third  day, 
medicinal  treatment  directed  to  cardiovascular  and  renal  inadequacy,  and  the 
conservative  use  of  urinary  antiseptics  (salol,  hexamethylenamine)  are  all 
measures  bearing  on  the  postoperative  result. 

The  mortality  of  operators  with  special  skill  in  the  performance  of  the 
operation  lies  between  three  and  five  per  cent.;  when  great  care  is  taken  in 
the  pre-operative  examination  and  treatment  of  patients  the  mortality  of  oper- 
ators of  average  skill  usually  lies  between  five  and  ten  per  cent.;  while  when 
these  precautions  are  not  taken  the  same  men  would  usually  have  a  mortality 
of  from  ten  to  twenty  per  cent. 

Epididymitis  after  Prostatectomy. — This  complication  follows  the  peri- 
neal and  suprapubic  operations  with  about  equal  frequency.  Usually  it  comes 
on  ■^^dthin  a  few  days  of  the  operation,  but  occasionally  not  till  weeks  afterward, 
when  the  patient  has  gone  home.  The  infection  is  accompanied  by  fever  and 
marked  toxaemia,  and  in  not  a  few  cases  has  had  a  fatal  termination. 

Epididymotomy  is  the  treatment  of  choice,  on  account  of  the  danger  of  a 
lethal  termination,  and  the  promptness  of  the  relief  obtained  by  this  procedure. 
Xitrous  oxide  should  be  administered,  and  a  knife  plunged  into  the  region  of 
greatest  induration.  The  relief  seems  to  be  equally  prompt  whether  or  not 
pus  is  found.  If  an  abscess  is  located  a  gauze  or  tube  drain  should  be  inserted, 
otherwise  the  scrotum  should  merely  be  elevated,  and  a  compress  wet  with 
a  saturated  solution  of  magnesium  sulphate  be  applied. 

Castration  and  Vasectomy. — The  removal  of  the  testicles  or  sections  of 
the  vasa  has  been  performed  many  times  for  the  purpose  of  causing  reduction 
in  the  size  of  enlarged  prostates,  following  the  suggestion  of  one  of  us  (White), 
based  on  the  observation  that  the  prostates  of  dogs  atrophied  following  orchi- 


SURGERY  OF  THE  PROSTATE  427 

dectomy.  The  procedure  is  at  times  curative,  though  not  invariably  so,  and  on 
account  of  the  recent  advances  in  the  technic  of  prostatectomy  it  has  of  late 
fallen  into  disuse;  however,  it  is  still  to  be  considered  when  prostatectomy  is 
deemed  inadvisable,  either  because  of  the  condition  of  the  patient  or  of  the 
inexperience  of  the  operator.  Vasectomy  is  a  less  efficient  procedure  than 
orchidectomy. 

ATROPHY  OF  THE  PROSTATE 

In  exhausting  diseases  accompanied  by  general  wasting  of  the  entire  body 
marked  atrophy  of  the  prostate  may  occur.  Thus,  Thompson  noted  one  case 
in  which  the  gland  weighed  less  than  one  drachm.  Extreme  old  age  is  usually 
accompanied  by  wasting  of  the  prostate;  mechanical  pressure,  as  from  extra- 
vesical  tumor  or  prolonged  distention  of  the  bladder,  may  produce  the  same 
effect.  The  gland  may  also  be  partly  or  completely  destroyed  by  abscess- 
formation  followed  by  cicatricial  contraction  and  by  sclerosis  secondary  to 
chronic  inflammation.  In  certain  cases  the  prostate  is  congenitally  atrophic, 
this  condition  being  generally  associated  wath  other  malformations.  Castration, 
especially  if  performed  in  early  life,  is  always  followed  by  prostatic  atrophy; 
masturbation,  if  begun  early,  and  if  excessive  and  long  continued,  may  result  in 
a  similar  condition.     Symptoms  of  atrophy  are  practically  wanting. 

The  diagnosis  is   founded  upon  rectal  examination. 

Treatment  is  unavailing. 

PROSTATIC  CALCULI 

Thompson  has  shown  that  the  corpora  amylacea  are  so  constantly  found 
in  the  prostate  that  their  presence  can  scarcely  be  considered  abnormal.  In 
3'outh  these  bodies  are  usually  microscopic  in  size.  Later  in  life  they  become 
larger,  so  that  they  are  readily  seen  by  the  naked  eye.  The  name  corpora 
amylacfea  is  given  to  them  because  they  exhibit  a  granular  nucleus,  probably 
made  up  of  degenerated  epithelial  cells  and  inspissated  mucus,  about  which 
are  formed  concentric  layers  composed  of  an  albuminoid  substance,  and  pre- 
senting the  microscopic  appearance  of  starch  cells. 

When  the  corpora  amylacea  are  small  they  occasion  no  symptoms:  as 
they  grow  larger  they  act  as  foreign  bodies,  exciting  inflammation,  and  have 
deposited  in  and  upon  them  the  salts  of  lime,  calculi  being  thus  formed.  The 
calculi  may  lie  separately,  each  in  its  own  pouch,  or  many  of  them  may  be 
placed  in  a  common  pouch,  when  often  adherent  to  one  another.  In  color 
they  are  brown  or  black,  with  a  smooth  polished  surface,  exhibiting  facets  when 
a  number  of  calculi  are  placed  together  in  a  single  pocket.  They  are  made  up 
of  calcium  phosphate,  calcium  carbonate,  and  organic  matter,  and  are  com- 
monly found  below  the  urethra,  particularly  in  the  region  of  the  verumon- 
tanum.  If  by  ulceration  the  cavity  in  which  they  lie  opens  into  the  urethra, 
and  the  urine  has  access  to  them,  its  salts  will  be  deposited  upon  them,  causing 
rapid  growth,  abscess-formation,  and  ulceration,  usually  in  the  direction  of  the 
urethra,  but  sometimes  towards  the  bladder,  or  into  the  rectum  or  the  perineum. 

Prostatic  calculi  may  originate  in  the  substance  of  the  gland  as  just  de- 
scribed, may  come  from  the  bladder  or  the  urethra,  or  may  be  deposited  from 


428  GENITO-URINARY  SURGERY 

the  urine  in  suppurating  prostatic  pouches.  After  removal  of  the  prostate  there 
may  be  left  an  ulceratmg  cavity  which  gradually  becomes  filled  with  a  hard, 
calcareous  mass,  causing  obstructive  symptoms,  and  yielding  to  the  examining 
finger  the  wooden  induration  characteristic  of  cancer. 

Symptoms. — Until  prostatic  calculi  of  glandular  formation  open  into  the 
urethra,  symptoms  are  usually  wanting,  the  condition  not  being  generally 
recognized  until  it  is  shown  by  postmortem  examination  or  operation  performed 
for  some  other  pathological  condition.  When  the  calculi  begin  to  grow  from 
deposition  of  urinary  salts,  the  symptoms  of  posterior  urethritis  or  of  chronic 
prostatitis  develop. 

Diagnosis  is  founded  on  rectal  palpation  and  urethral  examination.  These 
calculi,  if  of  considerable  size,  can  generally  be  felt  by  the  finger  introduced 
into  the  rectum.  A  metal  catheter  will  give  a  grating  sound  as  it  is  introduced 
into  the  prostatic  urethra;  urethroscopic  examination  will  bring  the  concre- 
tions directly  into  view.    The  X-ray  gives  a  characteristic  shadow. 

Treatment. — It  is  sometimes  possible  to  remove  calculi  from  a  suppurating 
prostate  by  the  straight  or  slightly  curved  urethral  forceps.  A  perineal  ure- 
throtomy affords  the  safest  and  best  route  for  thorough  removal  of  these  concre- 
tions. The  median  perineal  incision  gives  enough  room;  exceptionally,  when  it 
is  necessary  to  make  a  careful  exploration  of  the  entire  prostate,  the  semilunar 
incision  in  front  of  the  anus  is  required,  the  anus  with  its  sphincter  and  the 
rectum  being  carried  backward,  the  prostate  exposed,  and  the  calculi  freed  and 
removed  through  the  incision.  For  the  very  small  calculi  which  pass  sponta- 
neously no  treatment  is  necessary  other  than  avoidance  of  all  causes  of  prostatic 
congestion,  as  constipation  and  alcoholic  or  sexual  excess.  When  in  consequence 
of  prostatic  calculi  there  are  harassing  pains,  undue  frequency  of  urination, 
retention  of  urine,  or  cystitis,  surgical  intervention  is  imperatively  indicated. 

TUMORS  OF  THE  PROSTATE 

Cysts  of  the  Prostate 

Cysts  of  the  prostate  are  either  hydatid  or  retention.  The  hydatid  cysts  are 
so  extremely  rare  that  symptomatology  based  on  clinical  experience  can  scarcely 
be  formulated.  The  symptoms  would  naturally  be  dependent  on  interference 
with  micturition  or  defecation,  and  pain. 

The  detection  of  a  fluctuating,  non-inflammatory  tumor  would  lead  to  a 
diagnosis. 

Retention  cysts  are  frequently  associated  with  hypertrophied  prostates,  but 
in  any  case  are  rare.  Usually  they  are  due  to  obstruction  of  the  prostatic 
follicles.  Exceptionally  the  cyst  may  be  due  to  narrowing  or  obliteration  of 
the  opening  of  the  utricle.  In  this  case  interference  with  micturition  may  readily 
occur.  English  found  five  examples  of  this  affection  out  of  seventy  postmortem 
examinations  of  newly-born  children. 

The  treatment  is  puncture  through  the  perineum,  evacuation,  and  drainage. 
In  the  case  of  infants  suffering  from  retention  of  urine,  rupture  of  the  cyst  may 
be  effected  by  the  passage  of  a  small  metal  instrument. 


SURGERY  OF  THE  PROSTATE 


429 


MALIGNANT  DISEASES  OF  THE  PROSTATE 
The  prostate  is  subject  to  both  carcinomatous  and  sarcomatous  degeneration, 
the  former  being  very  much  the  more  common. 

CARCINOMA 
Cancer  of  the  prostate  is  a  disease  of  men  over  forty:    about  fifty  per  cent, 
occurs  in  the  seventh  decade. 


Fig.  231. — Carcinoma  of  the  prostate;  gross  specimen  and  micro- 
scopic section.  (No.  4409,  Department  of  Surgical  Pathology,  Univer- 
sity  of   Pennsylvania.) 


430  GEXITO-URINARY  SURGERY 

From  a  clinical  standpoint  there  are  two  types  of  carcinoma  of  the  prostate, 
one  in  which  the  process  long  remains  within  the  capsule  of  the  organ,  and 
one  in  which  there  is  an  early  extension  beyond  the  limits  of  the  capsule, 
usually  upward  about  the  seminal  vesicles.  Extension  into  the  bladder,  into 
and  about  the  urethra,  and  into  the  rectum,  with  ulceration  of  these  structures, 
are  all  late  and  unusual  occurrences.  Metastases  are  also  usually  late  develop- 
ments; those  in  the  lymphatics  are  found  in  both  the  inguinal  and  abdominal 
nodes.  These  secondary  lesions  may  be  much  more  extensive  than  the  primary 
focus.  Metastases  to  the  bones,  especially  to  the  bodies  of  the  lumbar  vertebrae, 
are  by  no  means  rare,  and  may  precede  in  their  clinical  manifestations  the  signs 
of  prostatic  involvement. 

It  is  usual  for  all  lobes  of  the  prostate  to  be  involved  in  the  growth  (Fig. 
231);  possibly  the  posterior  lobe,  lying  between  the  ejaculatory  ducts  and  the 
posterior  capsule,  is  involved  first  by  preference,  but  certainly  it  is  not  in- 
variably the  site  of  the  onset  of  the  trouble.  It  occasionally  happens  that  small 
areas  of  carcinomatous  degeneration  are  found  in  presumably  benign  prostates 
o  "^'^ ^?%,"^^^^^^^^^^  removed  at  operation    (Fig.   232).     Such 

cases  may  remain  well  for  years,   or  be 
permanently  cured. 

Symptoms. — Caranoma_of_-tlie_4irxiSr 
tate  in  its  early  stages  causes  no  symptoms 
which  are  indicative_of  jthe_nature_of,^he_ 
trouble. 

The  first  symptoms  are  indistinguish- 
able from  those  of  prostatic  hypertrophy 
FTG.232.-Carcinoma  of  the  prostate.  Arising     of  a  benign  type,  difficulty  and  frequency 
from  cellular  hyperplasia  of  the  acini.  q£  urinatiou  being  the  most  common.    The 

difficulty  may  be  anything  from  a  slight  slowness  in  starting,  with  lack  of 
force  to  the  stream,  to  complete  retention;  and  the  frequency  from  a  scarcely 
noticeable  decrease  from  the  normal  interval  to  a  condition  of  continual  unrest, 
the  patient  attemping  to  empty  his  bladder  every  few  minutes. 

Pain  is  a  later  symptom,  comes  on  at  various  stages  in  the  course  of  the 
trouble,  is  present  in  various  degrees  and  in  a  wide  variety  of  locations,  from 
the  loins  to  the  feet,  though  the  usual  sites  are  the  bladder,  the  deep  perineum, 
urethra,  or  penis,  or  all  of  these  regions. 

Hsematuria  is  a  late  symptom,  usually  indicative  of  ulceration  into  the 
bladder  or  urethra;  in  the  earlier  stages  it  is  rather  less  frequent  than  in  benign 
hypertrophy. 

The  course  of  the  disease  may  be  rapid  or  slow,  a  matter  of  months  or 
years.  Usually  a  considerable  period  elapses  between  the  onset  of  symptoms 
and  the  invasion  of  the  periprostatic  tissues,  so  that  if  the  diagnosis  can  be 
made  at  the  onset  of  symptoms — not  always  an  easy  matter — radical  cure  is  an 
attainable  result  in  a  considerable  proportion  of  cases.  The  microscopic  ex- 
amination of  removed  prostates  shows,  according  to  Albarran,  changes  indicative 
of  beginning  malignant  degeneration  in  ten  per  cent,  of  cases. 

Diagnosis. — The  examination  of  the  gland  through  the  rectum  must  be 
depended  upon  for  the  diagnosis  of  early  cases  of  carcinoma,  or,  if  the  findings 


SURGERY  OF  THE  PROSTATE 


431 


thus  obtained  are  of  doubtful  import,  microscopic  examination  of  the  removed 
gland  must  be  resorted  to.  The  carcinomatous  prostate  is  harder  than  the 
normal  gland,  typically  of  a  woodeny  hardness  which  is  quite  characteristic. 
The  surface  of  the  organ  may  be  either  smooth  or  nodular,  so  the  conformation 
cannot  be  relied  upon  in  forming  an  opinion.  In  the  more  advanced  cases  the 
extension  of  the  growth  about  and  between  the  vesicles  is  easily  detected  and 
is  quite  characteristic,  the  only  danger  of  confusion  being  with  extensive  seminal 
vesiculitis;  the  nature  of  a  growth  which  is  running  riot  through  all  the  tissues 
of  the  pelvis,  the  "  prostato-pelvic  carcinosis  "  of  Guyon,  is,  of  course,  un- 
mistakable. 

Prognosis. — When  the  diagnosis  of  carcinoma  of  the  prostate  is  unmistak- 


FiG.  233. — Apparatus  for  suprapubic  drainage. 


_able  there  is  little  hope  for  cure.  Death  usually  occurs  from  exhaustion,  sepsis, 
or  pyelonephritis  incident  to  obsfnlction  or  ascending  infection. 
"  ^Treatment. — Hope  of  curing  carcinoma  of  the  prostate  can  only  be  enter- 
tained when  the  case  is  operated  upon  before  the  disease  has  extended  beyond 
the  limits  of  the  prostate,  by  a  method  which  includes  all  of  the  gland,  its 
capsule,  and  the  prostatic  urethra  in  the  tissue  excised.  The  operation  is 
best  performed  by  the  perineal  route  after  the  method  of  Young,^  in  which 
the  membranous  urethra  is  divided,  the  prostate  freed  and  drawn  down  into 
the  wound,  and  an  incision  made  through  the  bladder-wall,  beginning  in  front 
just  above  the  gland,  and  continuing  around  to  the  base  just  below  the  ureteral 
orifices.  The  anterior  portion  of  the  bladder  wound  is  then  sutured  to  the  urethra 
about  a  catheter,  while  the  posterior  portion  of  the  wound  is  closed  by  transverse 
sutures.     Incontinence  of  urine  is  to  be  expected  after  the  operation. 


^  Young,  in  "  Keen's  Surgery,"  vol.   iv,   p.  465. 


432 


GENITO-URINARY  SURGERY 


Palliative  Procedures. — While  a  catheter  can  be  passed  without  difficulty, 
regular  catheterization  is  the  treatment  of  choice  for  the  distress  caused  by 
retention  of  urine.  Later,  when  the  urethra  is  obstructed  by  the  encroach- 
ment of  carcinomatous  tissue,  drainage  of  the  bladder  by  means  of  a  supra- 
pubic cystostomy  is  the  method  of  choice  (Fig.  233). 


SARCOMA  - 

Sarcoma  of  the  prostate,  comparatively  rare,  occurs  at  any  period  of  life, 
from  infancy  to  old  age;  nearly  fifty  per  cent,  have  been  found  in  the  first 
decade. 

Sarcoma  usually  springs  from  the  upper,  posterior  part  of  the  prostate,  and 
grows  chiefly  in  an  upward  and  backward  direction.  For  this  reason  disturb- 
ance of  urination  is  a  relatively  late  symptom,  and  in  most  cases  the  tumor 
has  reached  enormous  size  when  it  is  first  discovered.     In  a  few  cases  the 

urethra  has  been  infiltrated,  and  sarcoma- 
tous projections  have  been  found  in  its 
lumen;  involvement  of  the  mucosa  of  the 
bladder  is  rare.  Practically  all  varieties  of 
sarcoma  have  been  found  in  the  prostatic 
tumor  (Fig.  234). 

The  earliest  symptoms  of  the  disease 
may  be  those  of  urinary  obstruction,  or 
attention  may  be  called  -to  the  growth  by 
pain,  or  rarely  by  obstruction  in  the 
rectum.  The  course  of  the  disease  is  more 
rapid  than  that  of  carcinoma,  but  in  some 
cases  symptoms  have  been  present  for  over 
a  year  when  the  patients  have  applied  for 
relief. 

Diagnosis  is  again  based  on  the  rectal 
examination  of  the  growth.  While  sarcomata  differ  much  in  their  conformation 
and  destiny,  it  is  unusual  to  find  one  as  hard  as  carcinoma,  or  even  as  a  benign 
prostatic  hypertrophy,  and  it  is  also  unusual  to  find  one  which  has  not  made 
its  way  beyond  the  sheath  of  the  gland.  Both  smooth  and  nodular  sarcomata 
are  encountered.  Some  are  so  soft  that  there  is  danger  of  mistaking  them 
for  abscesses. 

Treatment. — Few  cases  are  suitable  for  the  performance  of  operations, 
the  object  of  which  is  the  radical  cure  of  the  disease.  In  young  subjects  the 
best  results  seem  to  follow  the  drainage  of  the  bladder  by  suprapubic  cys- 
tostomy. In  adults  attempts  to  reestablish  normal  urination  by  the  removal 
of  part  of  the  growth  are  usually  successful,  and  by  this  means  patients  have 
been  rendered  comfortable,  so  far  as  their  urination  was  concerned,  for  as  long 
as  a  year. 

There  is  reason  to  hope  that  radium  may  be  curative  in  at  least  some  of 
these  sarcomatous  cases. 


Fig.  234.- 


-Photomicrograph  of  sarcoma  of  the 
prostate  (small  round  cell). 


CHAPTER  XIX 

SEXUAL  WEAKNESS  AND  STERILITY 

The  term  impotence  implies  a  lack  of  ability  to  perform  the  sexual  act. 
It  is  not  necessarily  associated  with  sterility,  nor  is  a  sterile  person  necessarily 
impotent.  Thus,  patients  whose  ejaculations  are  premature  and  whose  erec- 
tions are  feeble  or  wanting,  though  unable  to  have  sexual  relations,  may  dis- 
charge semen  swarming  with  living  spermatozoa;  while  those  who  are  particu- 
larly vigorous  in  sexual  congress  may  have  no  emissions,  or  may  emit  fluid 
entirely  devoid  of  living  spermatozoa. 

Impotence  in  the  male  may  be  due  to  congenital  or  acquired  deformity  or 
to  feebleness  or  deficiency  in  erection. 

Mechanism  of  Erection  and  Ejaculation 

In  the  ordinary  condition  of  the  penis  the  muscular  fibres  lining  the  tra- 
beculae  are  in  a  condition  of  tonic  contraction;  hence  the  spaces  are  obliterated. 
Moreover,  the  arteries  are  so  contracted  that  no  more  blood  is  furnished  than 
is  sufficient  for  the  nourishment  of  the  parts;  hence  circulation  is  carried  on 
as  in  other  parts  of  the  body.  When  the  impulse  is  sent  out  from  the  erection 
centre  the  arteries  dilate  and  the  muscular  structure  of  the  erectile  tissue 
relaxes;  hence  there  are  provided  an  increased  blood-supply  and  spaces  for 
its  accumulation.  At  the  same  time,  as  a  result  of  muscular  contraction,  the 
veins  carrying  the  return  blood  are  pressed  upon  and  congestion  is  thus  in- 
creased. As  a  result  the  erectile  tissue  becomes  turgid,  and  this  in  itself 
adds  to  the  tendency  to  engorgement,  since  the  fibrous  investment  of  the  penis 
is  put  upon  the  stretch,  and  thus  the  venous  return  is  materially  interfered 
with.  As  the  penis  becomes  tense  and  rigid  it  is  mechanically  carried  upward 
to  an  elevation  of  about  forty-five  degrees  by  the  action  of  the  suspensory 
ligament,  though  both  the  erector  penis  and  the  accelerator  urinae,  by  drawing 
downward  and  backward  upon  the  organ  behind  the  position  of  this  liga- 
ment, assist  in  maintaining  this  position.  Erection  is  finally  completed  by 
the  active  participation  of  the  perineal  group  of  muscles.  The  erector  penis, 
the  accelerator  urinae,  the  transversus  perinei,  and  the  compressor  urethrae 
by  tonic  contraction  with  clonic  accentuations,  materially  increase  the  venous 
congestion. 

With  all  the  factors  described  in  harmonious  action,  the  penis  becomes 
fully  erect;  its  hardness  is  dependent  upon  the  amount  of  engorgement  and 
the  density  of  its  fibrous  investment;  the  spongy  body  and  the  glans  are  never 
as  hard  as  the  cavernous  bodies. 

As  the  result  of  sexual  excitement,  coincident  with  erection,  the  testicles 
are  drawn  close  to  the  abdomen  by  contraction  of  the  dartos  and  of  the  mus- 
cular fibres  of  the  cord.  It  is  probable  that  the  spermatozoa  which  fill  the. 
epididymis  are  rapidly  carried  by  the  peristaltic  action  of  the  muscular  coat 
28  433 


434  GEXITO-URINARY  SURGERY 

of  this  tube  and  of  the  vas  to  the  ampulla,  from  which  dilatation,  the  ejacu- 
latory  duct  being  patulous,  spermatozoa  are  driven  into  the  prostatic  urethra. 
In  the  meantime,  as  a  result  of  the  active  congestion,  the  mucous  glands  and 
follicles  of  the  urethra  have  been  secreting  a  clear,  sUghtly  alkaline,  viscid 
mucus,  the  possible  purpose  of  which  may  be  the  neutralization  of  any  acid 
urine  which  may  remain  in  contact  with  this  tube.  At  the  time  of  orgasm 
the  muscles  of  the  prostate  vigorously  contract  as  the  compressor  urethrse 
muscle  becomes  relaxed:  thus  not  only  the  spermatozoa  and  the  contents  of  the 
seminal  vesicles,  but  also  the  prostatic  secretion,  are  driven  forward  into  the 
bulbous  urethra,  being  prevented  from  going  back  into  the  bladder  by  the  con- 
gestion of  the  erectile  tissue  of  the  verumontanum  and  also  probably  by  con- 
traction of  the  internal  sphincter  of  the  bladder.  Once  in  the  bulbous  urethra, 
the  semen  is  driven  forward  by  contraction  of  the  whole  perineal  group,  aided 
by  the  muscular  fibres  of  the  urethra. 

The  semen  is  a  composite  fluid,  made  up  of  the  secretions  of  the  testicles, 
seminal  vesicles,  prostate  glands,  Cowper's  glands,  and  the  urethral  crypts  and 
follicles.  It  is  a  gray  fluid,  becoming  gelatinous  on  ejaculation.  If  allowed 
to  stand  it  becomes  thin,  and  there  settles  from  it  an  opaque  deposit,  made  up 
of  spermatozoa,  over  which  lies  a  layer  of  about  equal  thickness  of  gray,  trans- 
lucent liquid.  The  characteristic  odor  of  semen  is  probably  given  to  it  by  the 
prostatic  secretion.  It  resembles  that  of  a  raw  potato.  Spermatozoa  at  the 
time  of  ejaculation  and  for  about  twenty-four  hours  afterwards,  if  evaporation 
is  prevented,  should  be  in  active  motion.  When  the  semen  is  deposited  in  the 
female  genital  tract,  spermatozoa  live  for  many  days.  After  standing  for  two 
or  three  da3^s,  healthy  semen  deposits  the  spermatic  crystals.  The  amount 
discharged  at  one  orgasm  is  from  one  to  two  drachms,  though  this  quantity 
is  subject  to  marked  variations. 

The  nerve-centres  for  erection  and  ejaculation  are  situated  in  the  lumbar 
cord,  the  fibres  passing  outward  from  the  erector  centre  being  termed  nervi 
erigentes. 

The  erector  centre  may  be  stimulated  by  reflexes  from  the  genitalia  or 
from  regions  associated  by  ner\^e  anastomosis,  by  the  direct  action  of  the  brain, 
or  by  injuries  or  diseases  of  the  spinal  cord.  Familiar  examples  of  erection 
from  reflex  action  are  afforded  by  the  morning  priapism  incident  to  a  full  blad- 
der; by  the  continued  erection  sometimes  associated  with  prostatic  calculus  or 
with  inflammation  of  the  posterior  urethra;  and  by  the  tendency  to  local  con- 
gestion exhibited  with  balanoposthitis.  The  effect  of  sights,  sounds,  odors,  or 
mental  conceptions  upon  the  erector  centre  is  too  well  known  to  require  com- 
ment.   After  fracture  of  the  lower  dorsal  spines  priapism  may  last  for  weeks. 

Before  considering  the  question  of  impotence  it  is  well  to  know  what 
constitutes  an  average  amount  of  sexual  strength.  A  man  between  his  twentieth 
and  fiftieth  year,  who  has  no  drain  upon  his  system,  such  as  is  required  by 
unusual  business  anxieties,  or  such  as  results  from  grief,  disappointment,  etc., 
should  be  able  to  have  intercourse  about  twice  a  week  without  experiencing 
any  sense  of  fatigue  or  exhaustion.  Idiosyncrasy,  surroundings,  or  habits  of  life 
may  so  affect  the  individual  that  a  much  more  moderate  indulgence  would  be 
hurtful.     Thus  those  of  lowered  vitality  from  excessive  work,  deficient  food, 


SEXUAL  WEAKNESS  AND  STERILITY  435 

or  organic  or  functional  diseases  may  find  indulgence  to  the  extent  above  given 
highly  injurious  or  even  impossible,  while  the  vigorous,  full-blooded  man, 
whose  life  is  spent  mainly  in  the  open  air,  may  far  exceed  this  limit.  The 
gauge  as  to  the  healthful  limit  of  intercourse  should  be  the  sensations  experi- 
enced afterwards.  These  should  be  rather  of  increased  power,  both  physical 
and  mental,  than  of  exhaustion. 

Erections  may  take  place  shortly  after  birth.  The  power  usually  departs 
about  the  sixty-fifth  year,  though  it  is  often  retained  ten  or  fifteen  years  longer; 
it  may  be  lost  as  early  as  the  fiftieth  year. 

IMPOTENCE 

From  a  clinical  standpoint  impotence  may  be  classified  as  follows:  (1) 
organic  impotence;   (2)  psychical  impotence;    (3)  atonic  impotence. 

•Organic  impotence  implies  the  existence  of  appreciable  lesions  which 
interfere  with  function.  These  may  involve  the  spinal  cord,  producing  sclerotic 
changes  either  in  the  lumbar  centres  or  in  their  afferent  or  efferent  nerve-fibres. 
Thus,  in  lumbar  ataxia,  in  syphilis  of  the  cord,  and  in  some  cases  of  myelitis, 
impotence  is  sometimes  an  early  symptom  of  the  nerve-affection.  This  is  com- 
paratively rare. 

The  majority  of  cases  of  organic  impotence  depend  upon  malformation  of 
the  external  genitals.  This  malformation  may  affect  the  penis,  the  testicles, 
both  these  organs,  or  the  surrounding  parts.  The  penis  may  be  absent,  may 
be  rudimental,  may  be  deformed,  may  be  hypertrophied,  may  be  multiple.  If 
the  organ  is  absent  or  exists  simply  as  a  rudiment,  cure  is  hopeless.  If  the 
mechanical  impediment  to  coitus  is  depended  upon  the  small  size  of  a  penis 
which  is  normal  in  other  respects,  the  case  is  not  beyond  help,  since  it  has 
been  shown  in  several  instances  that  use  has  been  quickly  followed  by  an 
increase  in  growth.  Thus,  Wilson  observed  a  man  of  twenty-six  years  whose 
penis  before  marriage  was  not  larger  than  that  of  an  eight-year-old  child.  Two 
years  after  marriage  this  organ  had  reached  its  normal  size.  In  the  treatment 
of  impotence  in  patients  with  organs  perfectly  formed  but  markedly  undersized, 
the  application  of  a  suction  apparatus  may  be  beneficial.  This  consists  of  a 
cylinder  which  is  fitted  over  the  penis  and  from  which  the  air  can  be  exhausted ; 
as  a  result  there  is  venous  congestion,  with  temporary  increase  in  the  size  of 
the  organ.  It  is  stated  that  this  increase  will  become  permanent  if  the  treat- 
ment in  continued  a  sufficient  length  of  time. 

The  abnormal  size  of  the  organ  may  be  an  impediment  to  coitus,  but  only 
relatively  so.  Sometimes  the  penis  is  congenitally  adherent  to  the  scrotum,  or 
is  fixed  to  the  groin  or  the  belly  as  the  result  of  cicatricial  contraction.  Here 
plastic  operations  will  be  necessary,  according  to  the  special  indications  of 
the  case. 

Hypospadia  is  a  frequent  cause  of  impotence,  since  the  downward  cun,'e 
of  the  organ  is  so  greatly  exaggerated  during  erection  that  intromission  is  impos- 
sible. Wounds  and  lacerations  of  the  floor  of  the  urethra,  sometimes  internal 
urethrotomy,  will  produce  the  same  incurvation. 

Fibrous  or  cartilaginous  indurations  of  either  the  sheath  of  the  penis  or  the 
erectile  tissue  materially  interfere  with  coitus,  not  only  because  of  the  distor- 


436  GENITO-URINARY  SURGERY 

tion  which  always  becomes  manifest  on  erection,  but  because  the  erectile  tissue 
anterior  to  this  point  of  induration  remains  entirely  flaccid.  These  indurations 
are  irregular  in  their  distribution,  and  are  common  in  the  rheumatic  and  the 
gouty. 

Deeper  fibrous  indurations,  also  interfering  with  function,  not  infrequently 
develop  after  gonorrhoea,  and  in  some  cases  syphilis  seems  to  be  a  factor  in 
the  growth  of  these  lesions.  When  they  appear  in  the  form  of  gummata  their 
specific  origin  is  sufficiently  obvious.    Calcification  sometimes  takes  place. 

The  treatment  of  this  condition  is  unsatisfactory.  Gummata  can  be  made 
to  resolve  under  specific  treatment.  The  hard  nodulations  and  indurated  plaques 
which  are  observed  in  gonorrhoea  or  in  goiit,  or  which  come  without  obvious 
cause,  are  extremely  obstinate.  Massage  and  inunctions  of  mercury  should  be 
employed,  together  with  pressure,  which  is  best  applied  by  means  of  a  thin 
rubber  bandage.    The  prognosis  as  to  cure  must  always  be  extremely  guarded. 

Aneurismal  dilatations  of  the  corpora  cavernosa,  whether  congenital  or  trau- 
matic, may  mechanically  prevent  coitus.  Relief  is  here  obtained  by  the  appli- 
cation of  firm  rubber  bandages  or  supports. 

Varix  of  the  dorsal  vein  of  the  penis,  though  it  may  attain  large  dimen- 
sions, rarely  produces  functional  disturbance.  If  it  does,  excision  is  the  proper 
remedy.  A  similar  condition  of  the  lymph-vessels  may  be  cured  by  excision, 
or  by  the  less  radical  means  of  passing  a  seton  through  the  vessel.  A  tight 
frsenum  should  be  remedied  by  incision. 

Tumors  or  swellings  about  the  genitalia  may  mechanically  interfere  with 
function.  Thus,  elephantiasis  of  the  scrotum,  enormous  oedema  of  the  prepuce, 
huge  scrotal  hernias,  and  immensely  protuberant  bellies,  large  scrotal  tumors, 
muscular  contractures,  hydroceles,  all  may  render  coitus  well-nigh  impossible. 

Malformations  and  diseases  of  the  testicles  may  also  produce  impotence. 
Such  deformity  is  not  necessarily  attended  with  any  malformation  of  the  penis, 
though  this  is  the  rule. 

In  anorchidism — that  is,  congenital  absence  of  the  testicles — impotence  is 
complete.  Cryptorchids  (those  whose  testicles  have  not  descended)  are  usually 
sterile,  but  not  impotent.  Removal  of  both  testicles  is  ultimately  followed  by 
impotence,  but  this  may  not  come  on  for  some  years. 

Disorganization  of  the  testicular  structure  either  from  inflammation  or  from 
tumor-growths  is  also  followed  by  the  loss  of  sexual  power.  If  the  inflamma- 
tion is  confined  to  the  epididymis,  however,  as  in  the  case  of  epididymitis,  the 
glandular  structure  of  the  testes  remaining  intact,  sterility  follows,  but  there  is 
no  loss  of  sexual  strength.  Syphilis,  tubercle,  sarcoma,  carcinoma,  even  though 
they  involve  but  one  testicle,  are  sometimes  associated  with  impotence.  The 
chronic  congestion  and  slow  atrophy  incident  to  pronounced  varicocele  are  not 
infrequently  followed  by  impotence  long  before  gross  changes  in  the  testicle 
are  noted. 

Psychical  Impotence. — In  this  form  of  weakness  the  sexual  organs  are 
normally  formed,  and  erection  is  possible,  but  is  not  properly  under  the  control 
of  the  will.  At  times  such  patients  have  vigorous  erections.  These  occur  in 
the  morning  and  on  comparatively  slight  provocation.  Under  certain  circum- 
stances, and  usually  at  times  when  this  failure  is  most  mortifying,  erections 


SEXUAL  WEAKNESS  AND  STERILITY  437 

fail  utterly,  or,  at  niost,  are  so  feeble  as  to  be  of  no  service.  This  form  of 
impotence  not  infrequently  attacks  the  newly  married,  who  fancy  that  they 
suffer  from  some  form  of  sexual  weakness  incident  to  early  self-abuse.  It  is 
sometimes  due  to  a  mental  impression  produced  by  failure  incident  to  fright, 
disgust,  or  other  emotions  at  the  first  attempt. 

Treatment. — The  treatment  of  these  cases  of  psychical  impotence  should 
be  one  calculated  to  make  a  strong  impression  upon  the  patient's  mind.  He 
must  be  examined  with  the  utmost  thoroughness  both  locally  and  generally. 
All  causes  of  local  irritation,  must  be  removed  and  every  effort  made  to  improve 
his  general  health;  he  should  be  assured  that  his  weakness  is  merely  tempo- 
rary and  that  cure  will  certainly  result.  Such  patients  have  generally  read 
pernicious  literature,  and  have  usually  consulted  charlatans:  hence  they  need 
to  be  disabused  of  the  teaching  that  masturbation  indulged  in  moderately  and 
for  a  short  time  invariably  produces  disastrous  results. 

In  addition  to  the  general  hygienic  directions,  including  regulation  of  the 
diet,  attention  to  the  bowels,  and  exercise,  some  medicine  should  be  given  to 
these  patients,  and  this  should  be  one  appropriate  to  their  general  condition, 
or,  if  the  health  is  perfect,  one  which  has  a  tendency  to  act  as  an  excitant  on 
the  spinal  centres.     Perhaps  the  best  prescription  is  the  following: 

B      Strychnins  sulph.,  gr.  ^/m; 

Phosphori,  gr.  Vi"<>; 

Damianas  ext.,  gr.  iii; 
M.  et  ft.  pil.  no.  i. 
S. — One  pill   three  times  a   day. 

Under  some  circumstances  moderate  stimulation  by  means  of  Burgundy 
or  champagne  may  be  beneficial,  since  the  patient  is  often  entirely  cured  after 
one  successful  effort.  Absolutely  forbidding  intercourse  acts  at  times  as  an 
excellent  stimulus.  Patients  suffering  from  this  form  of  impotence  should  be 
especially  cautioned  against  trials  of  their  powers  with  prostitutes,  since  the 
circumstances  of  these  trials  are  little  conducive  to  a  normal  degree  of  sexual 
excitement. 

The  term  relative  impotence  implies  lack  of  ability  to  perform  the  sexual 
act  with  certain  partners,  while  with  others  full  strength  may  be  preserved. 
No  rule  can  be  laid  down  for  the  management  of  such  cases.  Each  must  be 
conducted  in  accordance  with  its  merits,  the  physician  always  throwing  his 
influence  on  the  side  of  morality.  Much  can  sometimes  be  done  by  strong 
mental  impression,  usually  accentuated  by  the  administration  of  drugs.  In 
many  cases  impotence  upon  the  part  of  the  man  is  due  to  the  frigidity  of  the 
woman,  who  does  not  realize  the  profound  effect  of  her  attitude.  Perhaps  the 
best  plan  in  these  cases  is  to  advise  the  man  to  shun  the  society  of  other  women, 
to  live  well,  work  little,  exercise  much. 

Atonic  Impotence. — Under  this  heading  are  included  those  cases  of  partial 
or  complete  impotence  which  are  due  to  a  weakened  condition  of  the  lumbar 
centres.  \Mien  these  centres  are  in  their  normal  condition,  erection  should  be 
vigorous,  and  coitus  should  be  continued  for  from  three  to  five  minutes  before 
ejaculation,  and  after  ejaculation  there  should  not  be  immediate  subsidence  of 
erection.  In  many  healthy  young  men  the  erection  can  be  maintained  until 
two  emissions  have  taken  place. 


438  GEXITO-URINARY  SURGERY 

In  atonic  impotence  (1)  erections  may  be  vigorous,  but  ejaculations  may 
be  premature,  occurring  on  contact  or  even  before,  followed  by  immediate  sub- 
sidence of  erection;    (2)  erections  may  be  weak  or  may  be  entirely  w^anting. 

The  atonic  condition  of  the  lumbar  centres  may  be  dependent  on  certain 
general  conditions,  such  as  anaemia,  diabetes,  uraemia,  cholaemia,  and  rheuma- 
tism. Sometimes  temporar}^  impotence  is  one  of  the  first  signs  of  post-diph- 
theritic paralysis.  Wasting  diseases,  such  as  consumption,  are  usually  accom- 
panied by  this  form  of  atonic  impotence.  Many  drugs,  if  taken  until  their 
toxic  effects  are  produced,  occasion  failure  of  sexual  power.  Thus,  lead-poison- 
ing, carbonic  acid  gas,  carbon  bisulphide,  antimony,  and  particularly  alcohol, 
tobacco,  and  opium,  may  cause  complete  loss  of  both  power  and  desire.  Impo- 
tence resulting  from  the  excessive  use  of  tobacco  and  alcohol  often  long  outlasts 
the  other  bad  effects  after  the  habit  has  been  stopped.  Cjertain  persons  exhibit 
an  idiosyncrasy  towards  tobacco,  which,  when  taken  in  such  moderation  as  to 
produce  no  constitutional  effect,  may  destroy  both  sexual  desire  and  power. 
It  is  alleged  that  the  cigarette  is  particularly  potent  in  producing  this  result. 

According  to  Trousseau,  coffee  has  marked  anaphrodisiac  effects,  and  may 
produce  complete  impotence.  This  observation  is  certainly  not  in  accord  with 
the  experience  of  the  majority  of  surgeons,  at  least  so  far  as  the  moderate  use 
of  the  drug  is  concerned.  If  taken  in  enormous  quantities  it  may,  of  course, 
produce  this  result,  but  rather  because  of  the  general  nervous  breakdown  than 
because  of  any  special  action  on  the  sexual  centres.  Certain  drugs  given  in 
physiological  doses  wall  produce  a  marked  lessening  of  sexual  power.  The 
bromides  are  particularly  depressing;  cocaine  is  alleged  to  have  this  effect, 
and  morphine  in  certain  individuals  is  markedly  sedative  to  the  sexual  centres. 

In  accordance  with  the  degree  of  impotence  the  condition  is  said  to  be  either 
irritative  or  paralytic. 

In  the  irritative  form  the  erections  are  either  perfect  or  imperfect.  The 
emissions  are  always  premature,  quickly  followed  by  subsidence  of  erection. 
The  sexual  desire  is  strong. 

In  the  paralytic  form  erections  are  absent  or  feeble,  desire  is  wanting;  dur- 
ing orgasm  the  semen  drops  from  the  flaccid  penis,  with  little  or  no  pleasurable 
sensation. 

Of  these  two  forms  the  irritative  is  the  more  common.  The  cause  is  in  the 
great  majority  of  cases  a  diseased  condition  of  the  prostatic  urethra,  the  mucous 
membrane  being  exceedingly  hyperaemic,  or  chronically  inflamed,  keeping  the 
centres  for  erection  and  ejaculation  in  a  constant  state  of  reflex  excitability. 
This  condition  of  the  prostatic  urethra  may  depend  upon — (1)  gonorrhoeal 
inflammation  and  its  sequel,  stricture;  (2)  excessive  venery;  (3)  prolonged 
ungratified  sexual  excitement;  (4)  strongh^  acid  or  irritating  conditions  of  the 
urine.  Of  all  these  causes,  gonorrhoeal  inflammation  and  its  sequel,  stricture, 
are  the  most  frequent.  In  most  cases  of  acute  gonorrhoea  the  prostatic  urethra 
is  involved  to  a  very  slight  degree,  and  the  disease,  at  least  in  this  part  of  the 
tube,  undergoes  complete  resolution.  In  a  certain  percentage  of  cases,  however, 
the  disease  becomes  firmly  lodged  in  the  prostatic  follicles,  utricle,  ejaculatory 
ducts,  seminal  vesicles,  or  ampullae  of  the  vasa,  manifesting  itself  only  by  an 
occasional  apparently  causeless  outbreak  in  the  form  of  an  acute  attack.     As 


SEXUAL'  WEAKNESS  AND  STERILITY  439 

a  consequence  of  the  continued  irritation,  the  mucous  membrane  of  the  pros- 
tatic urethra  undergoes  catarrhal  alterations,  and  the  sensory  nerve  filaments 
so  rich  in  this  part  of  the  tube  are  involved  and  retiexly  excite  the  centres  for 
erection  and  ejaculation.  This  inflammatory  and  hypersesthetic  condition  of 
■  the  posterior  urethra  is  still  further  aggravated  by  the  formation  of  a  stricture. 

Atonic  impotence  from  sexual  excess  is  most  frequently  observed  among 
masturbators,  if  this  habit  can  properly  be  classed  as  "  sexual."  In  the  recently 
married  sexual  excess  is  by  no  means  uncommon,  but  shortly  regulates  itself. 
Occasionally  it  is  continued  for  a  long  time,  and  then  doubtless  works  perma- 
nent harm  by  producing  a  hypersesthetic  condition  of  the  posterior  urethra,  and 
consequently  one  of  the  forms  of  impotence. 

Masturbation  as  a  cause  of  impotence  is  generally  given  prominence  which 
is  not  deserved.  This  is  a  habit  which  practically  all  boys  have  had  at  one 
time.  The  popular  belief  as  to  the  injury  which  even  a  slight  indulgence  in  it 
may  cause  leads  those  who  subsequently  have  sexual  trouble  to  refer  this  back 
to  self-abuse.  Even  when  the  habit  is  continued  for  years  during  the  period  of 
youth  and  early  manhood  it  is  often  followed  by  no  appreciable  ill  effects:  at 
least  such  is  the  testimony  of  large  numbers  of  medical  students.  It  is,  how- 
ever, undoubtedly  true  that  in  certain  instances,  aside  from  the  rooted  convic- 
tion of  the  patient,  irritative  and  paralytic  forms  of  impotence  can  be  referred 
directly  to  excessive  masturbation.  The  physique  and  morale  of  a  masturbator 
are  popularly  considered  as  almost  pathognomonic.  Thus,  such  patients  are 
supposed  to  have  muddy,  pimpled  complexions;  a  cold,  moist  surface;  hollow, 
sunken,  blinking,  shifting,  watery  eyes;  lustreless  hair;  a  timid,  constrained 
manner;  stooping  shoulders;  a  tendency  to  swallow  frequently,  particularly 
on  being  embarrassed;  weak  knees;  a  shambling  gait;  shrunken  sexual  organs, 
and  a  solitary  disposition,  with  incapacity  for  any  intellectual  effort. 

This  description  no  doubt  applies  to  certain  aggravated  cases.  It  may, 
however,  be  observed  in  neurotics  who  are  not  addicted  to  the  habit,  and  an 
extreme  degree  of  masturbation  may  coexist  with  the  appearance  and  manners 
of  perfect  health. 

Atonic  impotence  from  prolonged  and  ungratified  sexual  desire  is  usually 
observed  in  men  of  neurotic  temperament,  particularly  those  coming  from  the 
rural  districts,  who,  from  the  circumstances  of  their  life,  are  exposed  to  sexual 
excitement,  and  who,  either  from  moral  reasons  or  for  lack  of  opportunity,  do 
not  indulge  in  sexual  intercourse.  Many  of  these  cases  can  properly  be  classed 
as  masturbators,  since  the  sexual  centres  finally  become  so  irritable  that  even  the 
mechanical  frictions  or  jarrings,  such  as  come  from  riding  on  horseback  or  in 
a  jolting  wagon,  occasion  emissions. 

In  these  cases  the  condition  of  sexual  neurasthenia  is  unusually  well  marked. 

Since  the  ordinary  lesion  of  atonic  impotence,  whatever  its  remote  cause 
may  be,  is  a  hyperaesthetic  condition  of  the  prostatic  urethra,  it  is  not  unrea- 
sonable to  suppose  that  the  irritation  incident  to  abnormal  conditions  of  the 
urine  may  excite  a  prostatic  hypersemia,  resulting  in  the  derangement  of  the 
sexual  centres.  That  this  is  the  cause  of  impotence  associated  with  certain 
abnormal  conditions  of  the  urine  cannot  be  positively  asserted,  since  it  is  pos- 
sible that  the  general  condition  which  occasions  the  abnormal  urine  may  also 


440  GEXITO-URIXARY  SURGERY 

operate  on  the  centre  presiding  over  erection.  Thus,  in  complete  impotence  a 
careful  examination  of  the  prostatic  urethra  may  fail  to  show  the  slightest  sign 
of  abnormal  prostatic  condition.  In  cases  of  oxaluria,  however,  the  return  of 
sexual  strength  is  often  coincident  with  the  disappearance  of  calcium  oxalate 
in  the  urine.  The  irritating  effect  of  acid  urine  on  the  prostatic  urethra  is 
shown  by  the  persistent  priapism  which  sometimes  accompanies  acute  attacks 
of  gout,  in  which  there  is  found  a  heavy  deposit  of  uric  acid. 

Genito-Urinary  Neuroses. — Atonic  impotence  is  characterized  by  certain 
local  and  general  symptoms,  which  Ultzmann  has  admirably  described  under 
the  general  heading  of  genito-urinary  neuroses.  He  states  that  the  symptoms 
incident  to  a  h^-persemic  or  chronically  inflamed  condition  of  the  prostatic 
urethra  are  almost  identical  with  those  observed  in  the  female  as  the  result  of 
endometritis.  Both  the  uterus  and  the  prostate  are  richly  supplied  with  nerves. 
In  men  the  bladder  and  seminal  vesicles  and  prostate  receive  filaments  from 
the  vesical  plexus,  which,  in  turn,  is  made  up  of  anastomosing  branches  from 
the  hypogastric  branch  of  the  sympathetic,  together  with  branches  from  the 
sacral  ganglia  and  from  the  pudendal  plexus  of  the  sacral  nerves.  This  nerve- 
supply  sufficiently  explains  why  irritation  of  the  prostatic  urethra  should  excite 
such  reflexes  as  pain  passing  down  the  inner  surface  of  the  thighs  or  referred  to 
the  hip,  the  anus,  the  hypogastric  region,  or  the  small  of  the  back. 

The  general  symptoms  are  those  of  neurasthenia.  Loss  of  mental  power, 
vertigo,  headaches,  shortness  of  breath,  indigestion,  palpitation,  colic,  cough, 
emaciation,  wandering  neuralgic  pains,  nervousness,  and  excitability, — these 
and  many  other  symptoms  of  which  neurasthenic  females  complain  are  dupli- 
cated in  the  male  suffering  from  atonic  impotence. 

The  urine  in  these  cases  is  often  abundant  and  of  low  specific  gravity. 
Sometimes  there  is  a  transient  glycosuria.  In  some  cases  the  urine  is  alkaline 
when  it  is  passed,  owing  to  the  presence  of  carbonates.  On  heating,  the  earthy 
phosphates  are  precipitated.  Indican  is  observed  particularly  in  those  given 
to  sexual  excess.  Transient  albuminuria  is  sometimes  noted.  Calcium  oxalate 
frequently  appears  in  great  excess.  The  amorphous  crystalline  salts  of  lime 
and  magnesia  are  also  to  be  found,  together  with  a  few  spermatozoa. 

The  sensory  neuroses  present  an  almost  infinite  variety.  The  usual  symp- 
toms complained  of  are  a  sensation  as  though  fluid  was  trickling  through  the 
urethra;  a  tickling  and  burning  feeling  at  the  meatus;  neuralgic,  aching,  or 
burning  pains  referred  to  the  testicles,  anus,  inner  surface  of  the  thighs,  hypo- 
gastric region,  small  of  the  back,  or  any  of  the  regions  innervated  by  branches 
communicating  with  the  hypogastric  and  sacral  plexuses;  pain  in  the  testicles 
and  burning  in  the  meatus  after  ejaculation;  and  extreme  sensitiveness  to  the 
passage  of  instruments.  In  aggravated  cases  the  urethra  becomes  anaesthetic, 
and  the  penis  feels  cold,  is  shrivelled,  and  is  sometimes  so  non-sensitive  that 
even  application  of  an  electric  brush  occasion  no  pain. 

The  motor  neuroses  of  the  urinary  and  genital  systems  may  take  the  form 
of  over-action  or  of  paralysis.  Vesical  irritability  is  sometimes  manifested  by 
paroxysmal  dribbling  or  even  complete  stoppage  of  the  urine,  occasioned  either 
by  a  lack  of  contraction  of  the  smooth  muscular  fibres  or  by  spasm  of  the  com- 
pressor urethrae.     So-called  stuttering  urine  may  be  due  to  the  same  cause. 


SEXUAL  WEAKNESS  AND  STERILITY  441 

When  the  detrusors  of  the  bladder  are  involved  in  over-action  there  is  difficulty 
in  retaining  water.  Urination  is  frequent  and  urgent,  and  is  usually  not  asso- 
ciated with  pain,  but  sometimes  there  is  marked  tenesmus.  Paralysis  of  the 
sphincters  or  detrusors  is  extremely  rare;  in  the  one  case  it  would  occasion 
dribbling  of  the  urine  and  in  the  other  retention.  The  motor  neuroses  of  the 
sexual  system  may  be  manifest  in  the  form  of  priapism,  or  of  partial  ox  complete 
impotence,  often  associated  with  involuntary  seminal  emissions  and  sperma- 
torrhoea. Priapism  is  observed  only  in  the  early  stages  of  acute  involvement 
of  the  prostatic  urethra;  impotence  is  common  in  chronically  inflamed  condi- 
tions. The  frequent  pollutions  complicating  it  are  due  to  spasm  of  the  detru- 
sors of  the  seminal  vesicles  and  the  vasa  deferentia.  Spermatorrhoea  or  drib- 
bling of  the  semen  without  the  sensation  of  an  orgasm  is  due  to  paresis  of  the 
muscular  fibres  of  the  ejaculatory  ducts. 

The  secretory  neuroses  of  the  genital  system  are  manifested  in  the  form 
of  polyspermia,  or  ejaculation  of  abnormal  quantity  of  semen;  aspermia,  or 
absence  of  semen;  or  prostatorrhoea,  a  discharge  made  up  of  the  secretions  of 
the  prostatic  glands,  the  glands  of  Cowper,  and  the  urethral  cr3^pts  and  follicles. 

The  Diagnosis  of  Atonic  Impotence. — A  careful  history  will  often  indi- 
cate whether  impotence  is  due  to  psychological  influence,  to  organic  changes,  or 
to  exhaustion  of  the  lumbar  centres.  Examination  should  be  made  not  only 
of  the  sexual  organs  but  also  of  the  heart,  of  the  lungs,  and  of  the  system  at 
large.  Examination  of  the  urine  should  never  be  omitted;  the  total  quantity 
in  the  twenty-four  hours,  the  specific  gravity,  the  reaction,  the  deposit,  the 
presence  or  absence  of  abnormal  constituents,  must  all  be  carefully  noted. 
Microscopic  search  will  determine  whether  or  not  pus  is  to  be  found.  The 
source  of  this  pus  must  be  discovered  in  the  method  described  when  consider- 
ing the  treatment  of  posterior  urethritis.  The  anus  should  be  explored  care- 
fully, since  lesions  in  this  region  may  excite  reflexes  which  are  referred  to  the 
genital  tract. 

Finally,  the  sexual  organs  must  be  carefully  examined;  the  testicles  are 
palpated,  and  their  size,  position,  consistence,  sensitiveness,  and  the  presence  or 
absence  of  swellings  and  new  growths  are  noted.  The  penis  is  similarly  exam- 
ined, its  circumference  behind  the  glans  recorded,  and  the  urethra  carefully 
palpated  for  indurations  along  its  track.  The  prepuce  is  subjected  to  careful 
scrutiny,  the  meatus  is  inspected,  and  finally  the  urethra  is  explored  exactly 
as  in  searching  for  strictures.  In  many  of  these  cases  spasmodic  contraction 
of  the  compressor  urethrae  muscle  is  particularly  marked.  A  full-sized  sound 
passed  to  the  membranous  urethra  and  kept  gently  pressed  against  its  anterior 
opening  will  finally  slip  through,  not  with  a  jump,  but  rather  as  though  an 
attempt  were  being  made  to  pass  it  through  a  tight,  flexible  tube  without  pre- 
viously lubricating  it.  Sometimes  it  seems  to  be  drawn  in  vdth  a  swallowing 
motion.  During  the  introduction  of  the  instrument  not  only  should  the  points 
of  resistance  to  its  entrance  be  noted,  but  also  areas  of  unusual  tenderness.  The 
posterior  urethra  is  extremely  sensitive;  in  cases  of  the  paralytic  type,  how- 
ever, the  passage  of  a  sound  is  absolutely  painless. 

If  the  meatus  is  so  narrowed  that  it  will  not  admit  a  full-sized  sound  it 
should  be  cut.    Urethroscopic  examination  is  rarely  necessary  in  these  cases,  at 


442  GENITO-URINARY  SURGERY 

least  until  the  failure  of  ordinary  treatment  suggests  the  possibility  of  some 
unusual  pathological  condition,  such  as  polypoid-  growth. 

An  examination  thus  conducted  will  show  a  hyperaemic  or  inflammatory 
condition  of  the  posterior  urethra,  either  associated  with  stricture  or  other 
obstructive  lesion,  or  simply  remaining  as  the  result  of  repeated  prolonged 
congestion  or  previous  acute  inflammation. 

The  prognosis  of  atonic  impotence  is  good,  except  in  the  most  advanced 
cases.  When  strictures  or  granular  patches  in  the  anterior  urethra  are  the 
exciting  causes,  the  cure  of  these  is  followed  by  the  disappearance  of  the  symp- 
toms of  impotence. 

"\Mien  the  symptoms  are  due  to  the  persistence  of  a  posterior  urethritis,  local 
applications  are  curative.  When  impotence  is  caused  by  impaired  health,  the 
outlook  is  favorable,  provided  the  general  condition  can  be  improved;  Even 
though  erections  are  entirely  absent  at  times  when  they  are  most  desired,  or 
are  of  such  short  duration  as  to  be  of  no  practical  service,  if  the  patient  has 
voluptuous  dreams  with  erection,  and  particularly  if  he  has  an  occasional  morn- 
ing erection,  the  chances  of  ultimate  cure  are  good.  The  prognosis  is  bad  only 
in  such  cases  as  have  no  erection  at  any  time,  the  semen  dribbling  without  pleas- 
urable sensations,  and  the  penis  being  cold,  shrivelled,  and  non-sensitive. 

Treatment. — The  treatment  of  atonic  impotence  must  be  both  general  and 
local.  The  daily  life  of  the  patient  should  be  carefully  regulated.  The  hours  of 
sleep,  the  diet,  the  amount  and  kind  of  exercise,  should  all  be  prescribed.  The 
bowels  should  be  kept  regular,  and  general  treatment  should  be  instituted  when 
this  is  required  to  combat  the  pathological  conditions  of  the  urine.  During 
treatment  the  patient  must  be  particularly  cautioned  against  venereal  excite- 
ment of  any  kind,  whether  from  reading,  conversation,  or  associations,  and 
against  testing  the  efficacy  of  his  treatment  by  an  occasional  trial  of  strength. 

All  sources  of  refle:x  irritation  must  be  removed.  Fissures  or  hemorrhoids 
in  the  rectum,  phimosis,  or  narrow  meatus  should  receive  prompt  surgical  treat- 
ment. Some  cases  of  impotence  have  been  cured  by  the  removal  of  a  hemor- 
rhoidal mass,  by  the  slitting  of  the  meatus,  or  by  treatment  directed  to  the 
destruction  of  lumbricoids  or  ascarides.  Even  a  moderate  degree  of  varicocele 
should  be  remedied  either  by  a  suspensory  bandage  or  by  operation. 

If  in  the  course  of  treatment  the  thoughts  are,  in  spite  of  every  effort,  turned 
to  sexual  topics,  the  patient  should  be  instructed  to  counteract  this  tendency 
in  its  very  beginning  by  vigorous  and  prolonged  exercise  and  cold  baths. 

The  local  treatment  has  for  its  end  the  restoration  of  the  entire  urethra  to 
a  normal  condition.  Strictures  must  be  cured  by  section  or  dilatation,  granular 
patches  healed  by  applications  through  the  endoscope,  and  hyperaesthetic  and 
inflammatory  conditions  of  the  posterior  urethra  treated  by  irrigation,  instilla- 
tions, and  the  passage  of  full-sized  cold  steel  sounds,  or  by  the  use  of  the 
psychrophore. 

The  sound  should  be  introduced  every  third  or  fourth  day  and  should  be 
of  full  normal  calibre.  'When  the  urethra  is  extremely  hyperaesthetic,  injections 
of  eucaine,  first  into  the  anterior  urethra,  then  into  the  posterior  part  of  the 
canal  by  means  of  an  instillator,  will  render  instrumentation  comparatively 
painless. 


SEXUAL  WEAKNESS  AND  STERILITY 


443 


When  there  are  distinct  evidences  of  congestion  or  inflammation  in  the  pos- 
terior urethra,  in  addition  to  the  sound,  irrigation  and  instillation  will  usually 
be  necessary  before  cure  can  be  accomplished.  (See  Treatment  of  Chronic  Pos- 
terior Urethritis.) 

When  inflammation  is  absent,  or  after  it  has  been  cured,  if  hypersesthesia 
still  persists,  this  is  best  combated  by  the  prolonged  application  of  cold.  The 
passage  of  a  cold  souhd  accomplishes  this  end  in  an  imperfect  way,  since  the 
metal  is  soon  heated.  The  psychrophore  (Fig.  235)  will,  however,  permit  of 
a  continuous  cold  application  for  as  long  a  period  as  is  desired.  This  instru- 
ment is  made  in  the  form  of  a  hollow  sound,  through  the  curved  extremity  of 
which  a  stream  of  water  of  the  desired  temperature  constantly  flows.  It  is  so 
devised  that  the  sheath  of  the  instrument  which  passes  through  the  anterior 
urethra  is  not  kept  cold  by  the  liquid,  which  flows  through  pipes  contained  in 


Fig.  235. — Psychrophore. 


the  sheath,  but  separated  from  its  walls  by  air-spaces.  It  is  only  in  the  ter- 
minal three  inches  that  the  water  is  allowed  to  come  immediately  in  contact 
with  the  walls  of  the  instrument. 

The  psychrophore  should  be  as  large  as  the  normal  calibre  of  the  urethra. 
It  is  introduced  until  its  curved  portion  occupies  the  membranous  and  pros- 
tatic urethrae;  then  a  current  of  water  of  the  desired  temperature  is  allowed 
to  pass  slowly  through  it,  thus  maintaining  the  chamber  at  its  end  at  about 
the  temperature  of  the  water.  In  cases  of  hypersesthesia  attended  by  the  irri- 
tative form  of  atonic  impotence,  cold  water  is  most  serviceable.  The  tempera- 
ture of  this  should  be  between  40°  and  50°  F.,  and  the  treatment  should  be 
kept  up  for  from  five  to  ten  minutes  every  second  or  third  day.  In  the  para- 
lytic form  of  atonic  impotence  hot  water  from  106°  to  110°  F.  should  be 
chosen. 

Heat  or  cold  may  be  applied  through  the  rectum  in  the  form  of  injections,  or 
a  rubber  bag  introduced  within  the  grasp  of  the  sphincter. 

Rectal  injections  are  so  planned  that  the  solution  of  choice  (sodium  chloride 
solution,  nine-tenths  per  cent.)  is  thrown  upward  in  a  forcible  stream  against 
the  prostate,  and  is  allowed  to  escape  immediately  without  distending  the  bowel. 
This  end  is  readily  accomplished  by  the  instrument  pictured  in  Fig.  203.  The 
selection  of  heat  or  cold  will  depend  upon  the  type  of  disease  and  the  sensations 
of  the  patient.    At  least  two  quarts  of  solution  should  be  used  daily.    Dry  heat 


444  GENITO-URINARY  SURGERY 

or  cold  through  the  rectum  is  readily  applied  by  means  of  a  modified  Barnes's 
bag  inserted  into  the  rectum  and  Oistenaed  with  either  hot  or  cola  water.  This 
method  of  treatment  is  to  be  commended  since  it  adds  to  the  beneficial  effects 
of  temperature  those  incident  to  pressure. 

When  by  the  means  already  described  urethral  h3^eraesthesia  has  been 
entirely  subdued  and  yet  impotence  still  persists,  other  methods  of  treatment 
must  be  employed  to  restore  power  to  the  weakened  centres  and  also  to  the 
muscles  concerned  in  erection  and  ejaculation.  Full  doses  of  strychnine  are 
advisable  in  these  cases,  and  particularly  strychnine  in  combination  with  phos- 
phorus and  damiana.    Massage  and  general  electricity  are  useful. 

The  needle  spray  applied  once  a  day  to  the  external  genitalia  at  the  time 
of  the  morning  bath  is  tonic  and  stimulating.  The  water  should  be  driven 
forcibly  against  the  inner  surfaces  of  the  thighs,  the  hypogastric  region,  the 
buttocks,  and  the  small  of  the  back,  and  should  be  alternately  as  hot  as  can 
be  borne  and  as  cold  as  possible.  The  applications  should  be  continued  for 
from  two  to  five  minutes. 

Electricity  is  one  of  the  most  valuable  means  of  stimulating  the  sexual 
centres.  Both  the  galvanic  and  the  faradic  current  seem  to  be  of  value.  It 
is  employed  not  only  as  a  general  nerve  tonic,  but  also  as  a  means  of  directly 
exercising  the  perineal  muscles  concerned  in  erection.  The  current  should  be 
first  applied  to  the  spine,  and  then  used  locally.  The  positive  pole  is  placed 
over  the  lumbar  region;  the  other  is  carried  to  the  perineum,  the  anus,  the 
hypogastric  region,  or  the  prostatic  urethra,  and  swept  over  the  external  geni- 
talia, the  buttocks,  and  the  inner  surface  of  the  thighs. 

The  rectal  electrode  is  serviceable  in  cases  of  imperfect  erection  and  loss 
of  power  of  ejaculation;  it  is  particularly  valuable  because  by  means  of  a 
slowly  interrupted  current  it  exercises  the  entire  perineal  group  of  muscles.  The 
important  part  these  muscles  play  in  erection  has  been  shown  already,  and 
restoration  of  their  vigor  by  the  use  of  electricity  may  be  followed  by  complete 
recovery  of  sexual  strength.  The  application  should  last  from  fifteen  to  twenty 
minutes  and  be  repeated  daily  for  several  weeks  or  months. 

The  urethral  electrode  allows  the  current  to  be  applied  directly  to  the  pros- 
tatic urethra.  Both  galvanic  and  faradic  currents  are  employed,  the  gauge 
as  to  strength  usually  being  the  sensation  of  the  patient.  An  electrode  properly 
placed  and  conveying  a  slowly  interrupted  current  strongly  exercises  the  sphincter 
of  the  bladder,  the  compressor  urethrse,  and  the  unstriped  fibres  of  the  prostate, 
probably  including  those  of  the  ejaculatory  ducts:  hence  in  cases  of  sperma- 
torrhoea this  treatment  is  particularly  serviceable. 

In  some  cases  which  do  not  yield  to  other  treatment,  a  complete  course  of 
hydrotherapy,  including,  as  it  does,  change  of  air,  surroundings,  and  occupation, 
is  sometimes  advisable,  or,  in  place  of  this,  prolonged  out-door  but  not  solitary 
life. 

Two  of  the  symptoms  of  atonic  impotence  are  so  conspicuous  as  to  deserve 
separate  consideration:  these  are  prostatorrhoea — that  is.  intermittent  discharge 
of  prostatic  fluid  from  the  urethra — and  spermatorrhoea,  or  involuntary  loss 
of  semen. 

Prostatorrhoea  is  characterized  by   a   discharge   during  defecation,   after 


SEXUAL  WEAKNESS  AND  STERILITY  445 

urination,  and  at  times  of  sexual  excitement,  of  a  white-of-egg-like  substance 
from  the  urinary  meatus.  This  same  substance  may  be  caused  to  flow  from 
the  meatus  by  pressure  upon  the  prostate  through  the  rectum.  Microscopic 
examination  of  the  discharge  shows  that  it  is  made  up  of  leucocytes,  cylindrical 
epithelium,  and  concentric  amyloid  concretions;  Bottchers  sperm  crystals  and 
casts  of  the  prostatic  ducts,  closely  resembling  renal  casts,  are  also  found. 
Blood  is  rarely  present. 

Prostatorrhoea  is  dependent  on  a  chronic  catarrhal  condition  of  the  prostate, 
involving  both  ducts  and  follicles.  Gonorrhoea  and  prolonged  ungratified  or 
unnaturally  gratified  sexual  excitement  most  often  produce  this  catarrhal  con- 
dition. On  examination  of  the  prostate  per  rectum  it  will  not  usually  be  found 
materially  increased  in  size,  although  occasionally  the  nodular  outline  indicative 
of  follicular  prostatitis  can  be  felt.  The  most  prominent  symptoms  of  this  con- 
dition are — (1)  A  marked  condition  of  sexual  neurosis,  perhaps  a  reflex  from 
the  catarrhal  condition,  usually  aggravated  because  the  patient  believes  that 
the  discharge  is  semen  and  that  thus  his  strength  is  draining  from  him.  (2)  A 
discharge  at  stool  and  after  urination  of  viscid  prostatic  mucus.  The  hyper- 
secretion is  going  on  steadily,  and  the  fluid  is  squeezed  from  the  gland  by  the 
passage  of  hard  fecal  masses  and  by  the  muscular  contractions  accompanying 
the  conclusion  of  the  act  of  urination,  and  is  allowed  to  pass  forward  by  the 
relaxation  of  the  compressor  which  occurs  in  both  urination  and  defecation.  In 
some  aggravated  cases  the  compressor  urethrae  muscle  becomes  so  weak  that  the 
discharge  will  flow  forward  almost  constantly.  If  many  spermatozoa  are  found 
in  the  discharge,  the  case  must  be  regarded  as  one  of  spermatorrhoea.  (3)  Fre- 
quency and  some  urgency  in  urination,  tickling  or  aching  sensations  in  the 
prostatic  urethra,  and  reflex  pains  in  the  back,  return,  hypogastrium,  and  dow^n 
the  inner  surface  of  the  thighs.  (4)  Partial  or  complete  impotence.  Excep- 
tionally, beyond  the  prostatic  discharge,  there  are  no  symptoms. 

Even  when  habitual  masturbation  causes  prostatorrhoea,  the  prognosis  is 
fairly  good,  provided  the  paralytic  form  of  impotence  has  not  been  reached 
and  the  patient  has  some  strength  of  will  on  which  to  build. 

Treatment. — The  treatment  is  especially  that  directed  to  the  cure  of  con- 
gestion or  inflammations  of  the  posterior  urethra.  When  a  depressed  condition 
of  the  system  or  irritating  urine  seems  to  be  the  cause  of  prostatorrhoea,  cor- 
rections of  these  departures  from  health  may  be  followed  by  prompt  cure. 

It  is  particularly  important  that  the  bowels  should  be  kept  open.  Paraffin 
oil,  cascara,  podophyllin,  magnesium  sulphate,  and  sodium  phosphate  are  the 
medicaments  of  choice.  Both  exercise  and  diet  must  be  carefully  regulated. 
Horseback  or  bicycle  riding  should  be  forbidden  only  to  those  whose  symptoms 
after  a  trial  are  made  distinctly  worse.  Often  these  exercises  provide  a  species 
of  massage  for  the  prostate  which  acts  most  beneficially  upon  it.  Prolonged, 
ungratified  sexual  excitement  will  render  abortive  all  treatment. 

When  there  is  pus  in  the  discharge  or  in  the  shreds  found  in  the  urine,  the 
treatment  is  that  appropriate  to  posterior  urethritis. 

The  medical  treatment  is  of  minor  importance,  but  should  none  the  less 
receive  attention.  When  the  inflammation  is  one  of  long  standing,  stimulants 
may  be  required.     Here  oil  of  sandalwood,  or  one  of  its  esters,  in  ten-minim 


446  GENITO-URINARY  SURGERY 

doses  three  times  a  day,  taken  one  hour  after  meals,  will  be  of  great  help. 
Cubebs,  copaiba,  turpentine,  and  cantharides,  the  latter  in  small  doses,  are  all 
useful.  When  the  bladder  is  irritable,  belladonna,  five  drops  of  the  tincture 
three  times  a  day,  is  beneficial.  When  the  urethra  is  especially  hyperaesthetic, 
and  particularly  in  cases  of  marked  sexual  neurasthenia,  potassium  bromide, 
administered  in  ten-grain  doses  three  times  a  day,  may  quiet  the  nervous  symp- 
toms. As  a  rule,  tonics,  compound  syrup  of  hj^ophosphites  in  teaspoonful 
doses,  emulsion  of  cod-liver  oil  with  iodide  of  iron,  and  iron  and  nux  vomica, 
should  be  recommended.  We  have  found  hyoscine  and  hyoscyamine  sulphate 
particularly  efficacious  in  the  non-inflammatory  forms  of  prostatorrhoea. 

It  is  upon  local  treatment,  however,  that  most  reliance  must  be  placed.  This 
consists  in  the  use  of  steel  sounds,  the  psychrophore,  the  prostatic  dilator,  the 
rectal  bag,  the  rectal  douche,  irrigations,  and  instillations. 

Instillations  in  these  cases  should  be  more  astringent  than  in  an  ordinary 
inflammatory  case:  thus,  fluid  extract  of  hydrastis  pure  or  zinc  sulphate,  twenty 
grains  to  the  ounce,  may  be  employed. 

The  prostatic  dilator  (see  Figs.  6  and  7)  is  of  service.  The  solutions  of  choice 
and  the  method  of  instrumentation  have  been  given.  (See  Chronic  Posterior 
Urethritis.)  Stretching  by  means  of  the  dilator  should  be  carried  as  high  as 
No.  36  of  the  French  scale  and  not  higher  than  No.  44.  Full  dilatation  of  the 
prostatic  urethra  by  means  of  ordinarj^  sounds  is  impossible,  since  an  instrument 
of  sufficient  size  to  overstretch  the  membranous  urethra  fits  loosely  in  the  wider 
prostatic  portion  of  the  tube. 

Perineal  counter-irritation  is  not  without  its  helpful  influence;  it  may  be 
applied  daily  by  freezing  a  spot  the  size  of  a  dollar  with  ethyl  chloride. 

Electricity  is  sometimes  a  useful  agent  in  prostatorrhoea.  The  galvanic 
current  is  most  popular,  one  pole  being  applied  to  the  lumbar  region,  the  other 
to  the  prostatic  urethra. 

Usually  it  is  best  strictly  to  interdict  intercourse;  though  when  prostatorrhoea 
occurs  in  married  men  as  the  result  of  long-continued  excess  it  is  wise  for  a 
time  to  allow  of  moderate  indulgence,  since  otherwise  the  local  congestion 
incident  to  prolonged  excitement  without  gratification  might  counteract  the  effect 
of  treatment.  The  advisability  of  allowing  moderate  intercourse  must  be  de- 
termined by  the  immediate  effect;  thus,  if  the  discharge  is  increased,  and  par- 
ticularly if  the  patient  feels  exhausted  and  suffers  from  lumbar  pains,  intercourse 
must  be  forbidden. 

Under  proper  treatment  recovery  may  result  in  from  one  to  three  months, 
though  in  some  cases  a  much  longer  period  of  time  is  required.  Certain  cases 
are  aggravated  by  local  treatment.  Under  these  circumstances  it  is  advisable 
to  make  a  complete  change  of  life  and  surroundings.  An  active  open-air  life 
will  sometimes  be  followed  by  ultimate  cure. 

Involuntary  Seminal  Emissions. — These  may  be  due  to  erotic  dreams,  or 
may  be  occasioned  by  a  local  hypersesthesia  so  marked  that  stimuli  too  feeble 
to  produce  any  effect  in  health  become  sufficient  to  excite  ejaculation.  The 
involuntary  emission  may  occur  at  night  or  in  the  day,  and  the  semen  may 
escape  intermittently  in  the  form  of  pollutions  or  as  an  almost  constant  flow. 

Nocturnal  Pollutions. — In  continent  men  it  is  entirely  compatible  with  health 


SEXUAL  WEAKNESS  AND  STERILITY  447 

to  have  nocturnal  pollutions  as  frequently  as  once  a  week.  When  during  the 
waking  hours  there  has  been  prolonged  sexual  excitement,  these  pollutions  may 
occur  much  more  frequently,  two  or  three  times  a  week,  and  yet  indicate  no 
abnormal  local  or  general  condition.  It  is,  however,  by  no  means  rare  to  find 
continent  men  who  have  no  pollution  for  weeks  or  months  at  a  time;  it  is 
especially  in  those  who  are  kept  constantly  occupied  both  in  mind  and  in  body 
that  this  is  observed.  After  prolonged  exertion,  either  mental  or  physical,  it 
is  not  uncommon  for  two  or  three  emissions  to  occur  in  a  single  night.  The 
pollutions  may  be  unattended  by  voluptuous  dreams,  and  may  occur  with  the 
penis  flaccid.  It  is  possible  for  the  variations  just  named  to  be  found  within, 
the  limits  of  perfect  health. 

The  gauge  as  to  whether  the  loss  can  be  considered  indicative  of  either  local 
or  general  weakness  is  the  condition  of  the  patient.  If  aside  from  imaginary 
sufferings  these  pollutions  are  followed  by  weakness,  backache,  and  mental 
depression,  if  they  are  habitually  frequent,  and  particularly  if  they  are  asso- 
ciated with  sexual  weakness  or  impotence,  they  must  be  regarded  as  an  index 
of  disordered  function.  At  first  nocturnal  pollutions,  even  though  they  occur 
with  extreme  frequency,  are  usually  associated  with  full  sexual  strength;  later^ 
as  the  excitability  of  the  ejaculatory  centre  becomes  weakened,  there  is  usually 
developed  a  more  or  less  profound  form  of  sexual  weakness. 

Diurnal  pollutions  indicate  a  degree  of  sexual  weakness  much  more  marked 
than  do  even  excessive  seminal  losses  occurring  during  sleep.  In  these  cases  the 
slightest  psychical  or  physical  stimulus  is  often  sufficient  to  excite  emission. 
The  presence  of  women,  the  jarring  of  a  wagon,  manipulations  necessary  for 
cleaning  the  foreskin,  or  even  examination  of  the  skin  surface  around  the  geni- 
talia, may  occasion  pollutions.  The  erections  are  usually  imperfect,  the  voluptu- 
ous sensations  are  blunted,  and  immediately  after  emission  there  is  subsidence 
of  the  erection. 

Spermatorrhoea. — This  condition  is  characterized  by  oozing  out  of  the 
semen  without  erection  or  pleasurable  sensation.  It  is  occasioned  by  erotic 
thoughts,  or  by  light  mechanical  stimuli,  or  may  occur  independently  of  these 
causes,  the  semen  escaping  with  the  urine  or  during  defecation  as  in  pros- 
tatorrhoea. 

Spermatorrhoea  in  the  sense  of  a  constant  flow  of  semen  from  the  urethra 
is  extremely  rare.  In  vigorous  men  much  given  to  sexual  excess  who  become 
suddenly  continent,  a  whitish  discharge  is  observed,  which  on  examination  is 
found  to  be  swarming  with  spermatozoa.  This  is  a  transitory  condition  un- 
associated  with  impotence,  and  with  but  a  moderate  degree  of  sexual  hj^Do- 
chondriasis.  Slight  and  intermittent  spermatorrhoea  is  comparatively  common 
in  chronic  posterior  urethritis,  even  when  there  is  no  appreciable  functional 
weakness. 

A  typical  sufferer  from  spermatorrhoea  represents  the  most  aggravated  form 
of  impotence.  Both  desire  and  the  -power  of  erection  are  usually  lost,  and 
voluptuous  sensations  are  excited  only  by  the  strongest  stimuli. 

The  diagnosis  of  spermatorrhoea  must  be  founded  on  microscopic  examina- 
tion. A  few  spermatozoa  in  a  mucous  discharge  do  not  indicate  any  patho- 
logical condition.    If  great  numbers  are  constantly  present  in  the  urine  and  in 


448  GENITO-URINARY  SURGERY 

the  discharge  occurring  after  defecation  or  urination,  it  may  be  assumed  that 
there  is  a  condition  of  true  spermatorrhoea. 

Treatment. — The  treatment  of  involuntary  seminal  emissions  is  that  appro- 
priate to  atonic  impotence,  since  both  these  conditions  are  symptomatic  of  an 
irritable  condition  of  the  lumbar  centres. 

The  treatment  of  nocturnal  pollutions  must  be  conducted  upon  rational 
principles.  First,  it  must  be  determined  whether  such  pollutions  indicate  an 
abnormality.  Usually  the  patients  applying  for  the  relief  of  this  condition  have 
seminal  losses  not  more  frequently  than  is  consistent  with  perfect  health.  When 
the  loss  is  excessive,  or  even  when  it  is  strictly  confined  within  normal  limits, 
if  the  patient  is  markedly  hypochondriacal,  a  vigorous  treatment  should  be 
instituted.  General  hygienic  directions  are  given;  the  patient  is  particularly 
cautioned  against  sexual  excitement.  By  means  of  a  saline  or  other  mild  laxative 
the  bowels  are  opened  at  night  before  retiring.  The  bed  should  be  hard,  the 
covering  light;  sleeping  in  the  dorsal  decubitus  should  be  avoided  by  tying  a 
towel  around  the  waist  with  a  knot  over  the  spine.  An  alarm-clock  is  set  to 
ring  about  four  hours  after  the  time  of  going  to  bed,  the  patient  then  rising 
and  passing  water.  Before  going  to  bed,  light  calisthenics  to  the  point  of  per- 
spiration, cool  sponge  bath,  and  brisk  rubbing  down  are  advisable. 

When  in  spite  of  these  precautions  erections  and  emissions  occur,  an  anti- 
pollution ring  may  be  worn.  This  is  designed  to  fit  comfortably  about  the 
penis  when  the  organ  is  in  its  flaccid  condition ;  when  it  becomes  erect  a  number 
of  sharp  teeth  dig  into  the  skin  and,  by  the  pain  they  excite,  wake  the  patient. 
All  sources  of  reflex  irritation  must  be  sought  for  and  removed.  Medication 
directed  to  subduing  the  irritability  of  the  lumbar  centres  is  sometimes  most 
serviceable.  Potassium  bromide,  from  thirty  to  ninety  grains  at  bedtime,  is 
temporarily  useful.  Atropine,  one  three-hundredth  of  a  grain  three  times  a  day, 
or  twice  this  quantity  given  at  bedtime;  hyoscine,  one  one-hundred-and-fiftieth 
of  a  grain;  lupuline,  one-twentieth  of  a  grain  three  times  a  day;  and  mono- 
bromate  of  camphor,  five  grains  three  times  a  day,  are  all  serviceable;  hyoscya- 
mine  is  almost  a  specific. 

The  treatment  of  diurnal  pollutions  is  conducted  on  the  same  general  prin- 
ciples as  that  of  atonic  impotence,  except  that,  as  this  symptom  usually  denotes 
an  advanced  catarrhal  alteration  of  the  prostatic  urethra,  strong  applications  to 
this  portion  of  the  canal  are  usually  necessary.  In  addition  to  the  various 
instillations  the  solid  stick  of  silver  nitrate  may  be  used  advantageously.  The 
hot  rectal  douches,  the  needle  spray,  electricity,  and  the  treatment  appropriate 
to  nocturnal  pollutions  are  applicable  in  these  cases. 

In  cases  of  seminal  incontinence  (spermatorrhoea)  the  treatment  should  be 
directed  towards  restoring  tone  to  the  paretic  vessels  and  revitalizing  the 
exhausted  lumbar  centres.  Of  the  drugs  employed,  strychnine,  one-twentieth 
of  a  grain  four  times  a  day;  damiana,  five  grains  three  times  a  day;  phosphorus, 
one-hundredth  of  a  grain  three  times  a  day;  fluid  extract  of  ergot,  a  teaspoonful 
three  times  a  day;  and  arsenic  trioxide,  one-fortieth  of  a  grain  three  times  a 
day,  are  valuable.  Electricity  is  particularly  serviceable.  The  psychrophore, 
hot  rectal  douches,  strong  posterior  applications,  particularly  the  solid  stick  of 


SEXUAL  WEAKNESS  AND  STERILITY  449 

silver  nitrate,  or  instillations  of  pure  iodine  or  of  iodine  and  carbolic  acid  mixed, 
will  give  the  best  results. 

Many  cases  of  sexual  weakness  are  made  worse  by  treatment.  If  after 
one  thorough  trial  of  methods  which  careful  examination  has  shown  most  likely 
to  be  successful  there  is  no  improvement,  local  treatment,  in  the  absence  of 
local  lesions,  should  be  abandoned,  the  physician  devoting  his  whole  attention 
to  the  improvement  of  the  general  health  of  the  patient. 

Priapism. — Persistent  erections  unaccompanied  by  sexual  desire,  at  times 
extremely  painful,  and  interfering  with  the  function  of  urination  are  usually 
expressions  of  spinal  lesion,  particularly  that  due  to  syphilis,  to  beginning 
sclerosis,  or  to  the  infiltration  of  leukaemia.  Cerebellar  hemorrhage  and  spinal 
trauma  sufficiently  severe  to  cause  paraplegia  also  produce  this  symptom. 
Interqiittent  priapism,  usually  annoying  rather  than  painful,  is  a  frequent  ac- 
companiment or  sequel  of  prolonged  mental  strain  in  neurasthenic  men. 

The  prognosis  is  grave  from  the  standpoint  of  the  causative  lesion. 

The  treatment  of  the  intermittent  neurasthenic  forms  of  this  affection  should 
aim  at  rest  and  improvement  of  the  general  health.  If  a  thorough  examination 
excludes  central  nervous  lesions,  then  patients  can  be  assured  that  the  symp- 
tom which  to  them  is  often  most  alarming  has  no  serious  significance,  and  that 
local  treatment  is  not  indicated.  Small  doses  of  hyoscyamin  sulphate,  gr.  ^/ooo, 
twice  daily,  are  often  serviceable,  but  bromides  or  other  depressants  are,  as  a 
rule,  distinctly  hurtful.  Exceptionally  a  local  lesion  such  as  chronic  posterior 
urethritis  may  cause  intermittent  priapism,  and  in  such  case  direct  treatment  is 
indicated.  Even  in  the  absence  of  local  lesions,  the  passage  of  a  sound  may  be 
helpful.  The  observance  of  general  hygienic  regulations  and  treatment  directed 
to  the  relief  of  gout,  rheumatism,  or  other  systemic  condition  which  may  require 
medication  are  followed  by  cure. 

Priapism  dependent  upon  syphilis  of  the  cord  calls  for  intravenous  admin- 
istration of  the  arsenical  preparations  and  massive  doses  of  mercury  and  the 
iodides.  When,  because  of  leukaemic  infiltrate  or  pressure  on  the  cord  from 
unremovable  tumor,  the  erection  becomes  persistent  and  hurtful  and  section  of 
the  pudic  nerves  may  be  needful  to  give  relief. 

Impotence  of  the  Female 

Impotence  in  the  female,  in  the  sense  of  inability  to  accomplish  the  sexual 
act  under  normal  and  lawful  conditions,  may  be  classified  under  the  following 
headings:  (1)  intromission  of  the  male  organ  is  impossible;  (2)  intromission 
is  possible,  but  either  excites  pain  or  fails  to  cause  orgasm. 

Intromission  of  the  male  organ  may  be  prevented  by  congenital  or  acquired 
obstruction,  or  by  obliteration  of  the  vulva  and  vagina.  The  congenital  anom- 
alies may  appear  in  the  form  of  absence  of  the  vagina,  extreme  narrowing, 
division  into  two  parts,  each  too  small  to  allow  of  intromission,  or  opening  in 
abnormal  positions,  as,  for  instance,  into  the  rectum.  The  vulva  may  be 
obstructed  by  adhesions,  by  hypertrophy  of  the  labia  or  clitoris,  or  by  a  rigid 
or  imperforate  hymen.  Acquired  obstruction  may  depend  upon  cicatricial  con- 
traction, inflammatory  swelling,  new  growths,  or  hypertrophy  of  the  parts. 
29 


450  GEXITO-URINARY  SURGERY 

The  treatment  of  impotence  dependent  upon  congenital  absence  of  the  vulva 
or  vagina  is  of  little  avail.  Cases  of  imperforate  hymen,  adherent  labia,  or 
mechanical  obstructions,  as  from  swellings  or  tumors,  can  be  remedied  only  by 
surgical  operation. 

Intromission  may  be  mechanically  possible,  but  may  be  resisted  or  entirely 
prevented  because  of  the  pain  occasioned  by  the  attempt.  Thus,  acute  inflam- 
mations about  the  vulva,  vagina,  uterus,  or  ovaries  will  render  sexual  approach 
extremely  painful;  urethral  canmcles,  urethritis,  fissures  of  the  neck  of  the 
bladder,  hemorrhoids  or  rectal  fissures,  ulcers  and  displacement  of  the  womb, 
inflammation  of  the  Fallopian  tubes,  and  disease  or  prolapse  of  the  ovaries, 
are  frequentty  observed  as  causes  of  this  condition. 

Usually,  on  account  of  the  pain,  the  perineal  muscles  become  spasmodically 
contracted  and  intromission  is  impossible.  Sometimes  this  spasm  does  not  occur 
until  entrance  is  accomplished,  in  which  case  the  male  organ  may  be  so  tightly 
imprisoned  that  release  is  accomplished  only  when  the  muscles  of  the  female 
are  relaxed  by  ether.  It  is  customary  to  class  vaginismus  among  the  pure 
neuroses.  A  careful  search  will,  however,  in  almost  every  case  reveal  an  inflam- 
matory area  from  which  the  reflex  starts.  In  most  of  these  cases  the  origin  of 
the  reflexes  is  to  be  found  in  fissures  in  the  neck  of  the  bladder;  urethral 
caruncle  and  urethritis  are  also  frequent  causes  of  vaginismus.  As  a  very  rare 
exception  the  only  pathological  condition  to  be  detected  is  an  apparently  cause- 
less hypersesthesia  of  the  vaginal  mucous  membrane. 

The  treatment  of  vaginismus  depends  for  successful  issue  upon  the  skill  and 
thoroughness  with  which  local  examination  is  made  for  the  source  of  the  reflexes. 
In  the  absence  of  any  cause  discoverable  by  palpation  or  inspection  of  the 
genitalia,  a  thorough  endoscopic  examination  of  the  bladder  is  indicated. 

The  cure  of  vaginismus  depends  upon  the  cure  of  its  exciting  causes.  Where, 
as  is  usually  the  case,  there  are  found  several  abnormal  conditions,  each  of 
which  may  possibly  be  responsible,  such  as  extensive  fissure  in  ano,  chronic 
endometritis,  and  granular  urethritis  near  the  neck  of  the  bladder,  all  these 
abnormal  conditions  should  be  remedied. 

In  the  absence  of  any  local  pathological  condition,  vaginal  douches  of  hot  one 
per  cent,  soda  solution,  followed  by  the  application  of  ten  per  cent,  cocaine 
solution  to  the  vulva  and  the  lower  portion  of  the  vagina,  may  render  introitus 
comparatively  painless.  These  patients,  belonging  as  they  do  to  a  neurotic 
type,  should  receive  treatment  appropriate  to  their  general  condition. 

STERILITY 

Sterility  in  the  male  is  that  condition  in  which  there  is  loss  of  procreative 
power.  This  necessarily  implies  absence  of  living  spermatozoa,  since  these  are 
the  elements  essential  to  impregnation,  but  it  does  not  imply  failure  of  power  in 
sexual   congress. 

Failure  to  bear  children  on  the  part  of  married  women  is  due  in  a  certain 
proportion  of  cases  to  sterility  of  the  husband.  The  definite  percentage  cannot 
be  given,  since  the  whole  subject  is  somewhat  obscure.  Thus,  it  is  well  known 
that  a  marriage  may  remain  barren,  but  that  each  partner  of  this  marriage, 
after  other  sexual  relations,  may  become  a  parent.     The  percentage  of  sterile 


•    SEXUAL  WEAKNESS  AND  STERILITY  451 

husbands  in  childless  marriages  has  been  variously  calculated  at  from  five  to 
twenty. 

The  composition  and  physical  qualities  of  normal  semen  have  been  already 
described.  The  total  quantity  and  the  number  of  spermatozoa  are  markedly 
diminished  by  sexual  excess  and  wasting  diseases.  Sterility  may  be  manifest 
by- 

(1)  Aspermia,  entire  absence  of  semen. 

(2)  Ohgospermia,  diminution  in  the  quantity  of  semen. 

(3)  Azoospermia,  absence  of  spermatozoa. 

Aspermia  is  a  condition  in  which  no  seminal  fluid  is  ejaculated,  though 
the  act  of  coitus  may  be  performed  normally  in  other  respects.  Aspermia  may 
be  due  to  imperfect  coordination  of  the  muscles  of  ejaculation;  sometimes  it 
is  an  expression  of  sexual  weakness.  In  this  case,  though  there  is  no  escape 
of  semen  during  orgasm,  it  may  subsequently  drop  from  the  end  of  the  flaccid 
penis. 

More  rarely  there  may  be  seminal  emissions  only  during  sleep,  prolonged 
and  repeated  efforts  utterly  failing  to  produce  emission  during  or  after  coitus. 
In  this  case  incoordination  probably  involves  the  muscles  which  force  the 
seminal  fluid  into  the  prostatic  urethra  and  the  dilatation  of  the  bulb,  or  failure 
in  emission  may  be  due  to  sensory  paralysis. 

As  a  modification  of  this  form  of  aspermia,  patients  are  seen  in  whom  ejacu- 
lation sometimes  takes  place  during  coitus  and  sometimes  cannot  be  excited. 

The  common  cause  of  aspermia  is  obstruction  of  some  portion  of  the  urethra. 
This  obstruction  may  be  congenital  or  acquired.  The  acquired  form  may  be  due 
to  traumatism  or  inflammation.  When  inflammation  has  attacked  and  destroyed 
the  greater  portion  of  the  secreting  substance  of  the  prostate,  and  has  blocked 
the  ejaculatory  ducts,  after  orgasm  there  will  be  a  discharge  of  two  or  three 
viscid  drops,  representing  the  secretion  of  Cowper's  glands  and  the  urethral 
crypts  and  follicles.  Tuberculous  infiltration,  malignant  degeneration,  the  pres- 
sure of  tumors,  tight  stricture,  or  the  blocking  of  the  passage  by  a  prostatic  or 
cystic  calculus  may  produce  aspermia.  Injury  to  the  ejaculatory  ducts,  with- 
out involvement  of  the  prostate,  will  cause  diminution  in  the  quantity  of 
semen  secreted  and  absence  of  spermatozoa,  but  not  aspermia,  since  the  pros- 
tatic secretion  is  ejaculated  and  presents  at  least  the  gross  physical  attributes 
of  normal  semen. 

The  term  false  aspermia,  or  malemission,  is  sometimes  employed  to  designate 
that  condition  in  which  semen  is  discharged  into  the  urethra  but  does  not 
reach  the  meatus,  either  passing  back  into  the  bladder  to  be  voided  with  the 
urine  or  exuding  drop  by  drop  from  the  urethra  after  coitus  has  been  completed. 
This  is  commonly  due  to  stricture,  which  may  be  of  such  calibre  as  not  to 
interfere  with  the  function  of  micturition  when  the  circulation  of  the  parts  is 
in  its  ordinary  condition,  but  which  so  encroaches  upon  the  urethral  calibre 
as  the  result  of  congestion  incident  to  erection  that  the  passage  is  practically 
obliterated.  Another  form  of  malemission  is  the  condition  in  which  the  semen 
is  not  properly  ejaculated  into  the  vagina  because  of  some  defect  in  the  urethra, 
such  as  hypospadia,  epispadia,  or  urethral  fistula.  Such  a  patient  is  neither 
sterile  nor  impotent,  yet  he  may  be  incapable  of  impregnation. 


452  GEXITO-URINARY  SURGERY 

Oligospermia,  or  a  diminution  in  the  quantity  of  semen  ejaculated,  may 
indicate  deficiency  in  total  quantity  or  absence  of  any  of  the  constituent  parts 
of  this  fluid.  Oligospermia  may  be  due  to  general  weakness,  debilitating  dis- 
ease, sexual  neurasthenia,  sexual  excesses,  masturbation,  or  any  of  the  various 
inflammatory  or  infiltrating  affections  which  obliterate  the  ducts  of  the  glands 
the  secretion  of  which  goes  to  make  up  the  semen. 

Oligozoospermia  indicates  a  condition  in  which  the  semen  ejaculated  con- 
tains a  few  spermatozoa.  As  a  transitory  condition  it  may  be  observed  in 
healthy  men. 

Azoospermia,  or  absence  of  spermatozoa  in  the  semen,  may  be  due  to 
absence  of  both  testes,  to  failure  of  the  testes  to  produce  spermatozoa,  or  to 
mechanical  obstruction  in  some  portion  of  the  passage  by  which  spermatozoa 
reach  the  urethra,  though  the  testicles  may.  fait  to  secrete  spermatozoa  when 
there  is  bilateral  retention,  atrophy,  or  malignant,  syphilitic,  or  tuberculous 
degeneration.  Congenital  absence  of  the  vasa  has  such  effect.  Even  unilateral 
affections  of  the  testicles  cause  azodspermia.  Prolonged  exposure  of  the  scrotum 
to  the  X-ray  produces  oligonecrospermia  or  true  azoospermia. 

The  ordinary  cause  is  bilateral  gonorrhoeal  epididymitis.  This  is  followed 
by  azoospermia  in  a  small  percentage  of  cases,  though  not  in  the  majority  of 
those  carefully  treated;  the  obstruction  is  usually  placed  in  the  tail  of  the 
epididymis,  but  healthy  spermatozoa  continue  to  be  formed  in  the  testis,  this 
gland  departing  from  type  in  that  obliteration  of  its  excretory  duct  has  no 
effect  upon  its  function.    Sexual  excess  produces  temporary  azoospermia. 

It  is  to  be  remembered  that  the  semen  discharged  by  those  suffering  from 
azoospermia  may  be  normal  in  odor,  consistence,  and  primary  gelatinification. 
On  standing  the  white  deposit  is  thinner;  on  microscopic  examination  the 
absence  of  spermatozoa  is  at  once  detected.  This  semen  deposits  the  spermatic 
(Bottcher)  crystals  very  rapidly. 

Alterations  in  the  color  of  the  semen  have  been  occasionally  observed.  It 
may  be  red  from  admixture  with  blood  due  to  inflammation  or  intense  con- 
gestion of  the  vesicles,  vasa,  or  prostatic  urethra.  Unless  the  bleeding  has  been 
recent,  the  color  will  be  a  dirty  chocolate.  A  large  quantity  of  pus  mixed  with 
the  semen  may  give  it  a  yellowish  or  greenish  tint.  Indigo  is  sometimes  found 
as  a  coloring  matter,  and  is  said  to  impart  a  reddish  color  to  the  fluid  much 
like  that  due  to  admixture  with  blood. 

Treatment. — Sterility  dependent  upon  absence  or  imperfect  development 
of  an}'-  portion  of  the  secreting  or  excreting  apparatus  is  incurable.  When  due 
to  gonorrhoeal  epididymitis  of  comparatively  recent  origin  it  usually  proves 
amenable  to  the  treatment  described  under  the  head  of  gonorrhoeal  epididymitis. 
When  the  obstruction  persists,  we  have  succeeded  in  relieving  it  by  performing  an 
anastomosis  between  the  vas  and  that  portion  of  the  epididymis  to  the  testicular 
side  of  the  obstruction.  The  vas  lies  behind  the  spermatic  artery,  which  sends 
its  main  branches  fon\^ard  to  the  inner  side  of  the  epididymis,  anastomosing 
freely  at  this  point  ^^ith  the  artery  of  the  vas.  The  epididymis  is  approached 
from  its  outer  side.  A  portion  of  the  head  is  picked  up  in  toothed  forceps  and 
excised.  If  this  excision  is  made  on  the  testicular  side  of  the  obstruction  there 
will  ooze  from  the  wound,  semen  which  contains  motile  spermatozoa.     The 


SEXUAL  WEAKNESS  AND  STERILITY 


453 


lumen  of  the  vas  is  opened  by  a  longitudinal  cut  one-quarter  of  an  inch  long. 
Into  this  wound  of  the  epididymis  the  vas  is  implanted  by  means  of  four  fine 
silver-wire  sutures,  carried  on  small  face  needles  from  the  outer  surface  of  the 
vas  into  its  lumen;  thence  from  the  cut  surface  of  the  opening  made  into  the 
epididymis  through  its  fibrous  tunic  (Fig.  236).  Because  of  the  smallness  of 
the  structures  involved,  the  operation  is  tedious  rather  than  difficult.  Aside 
from  the  ordinary-  surgical  instruments,  there  will  be  needed  a  sharp-pointed  pair 


Fig.  236. — Anastomosis  between  the  vas  deferens  and  the  head  of  the  epididymis.  A, 
opened  tubules  of  epididymis;  B,  mucosa  of  vas;  C,  vas  sutured  to  epididymis;  D,  head  of  epididy- 
mis; E,  tunica  vaginalis  testis;  F,  cord. 

of  scissors,  a  slender  bistoury,  and  a  grooved  director,  such  as  are  used  by 
ophthalmologists. 

Before  performing  this  operation  chronic  posterior  urethritis,  vasitis,  and 
vesicuhtis  must  be  cured.  During  the  course  of  the  treatment  indicated,  par- 
ticularly if  it  be  supplemented  by  massage  of  the  epididymis,  with  counter- 
irritation  and  the  wearing  of  a  suspensory  bandage,  the  spermatozoa  will  some- 
times reappear  in  the  emissions.  The  patency  of  the  ejaculatory  ducts  may 
be  determined  by  injecting  at  the  time  of  operation  watery   suspensions  of 


454  GENITO-URINARY  SURGERY 

indulin  and  carmine  into  the  lumen  of  each  vas  as  it  is  opened,  noting  upon 
which  side  each  has  been  used.  At  the  conclusion  of  the  operation  vesicular 
stripping  will  usually  express  from  the  urethra  some  of  the  coloring  matter,  or 
the  first  urination  will  exhibit  it;  the  first  subsequent  emission  will  surely  show 
it  if  there  be  no  obstruction  beyond  the  point  of  anastomosis.  The  operation 
will  render  fertile  about  fifty  per  cent,  of  those  upon  whom  it  is  performed, 
provided  there  be  no  obstruction  beyond  the  site  of  anastomosis.  When  the 
sterility  is  dependent  upon  blocking  of  the  common  ejaculatory  duct,  no  treat- 
ment has  been  suggested  which  promises  favorable  results. 

Sterility  dependent  upon  stricture  is  cured  by  full  dilatation  of  the  urethra. 
If  due  to  muscular  incoordination,  tonic  or  stimulant  treatment  directed  to  the 
general  nervous  condition  may  be  beneficial.  That  form  of  sterility  which  is 
apparently  dependent  upon  chronic  suppuration  of  the  prostatic  urethra,  ejacu- 
latory ducts,  seminal  vesicles,  and  ampullae  of  the  vasa  is  best  treated  by 
massage,  combined  with  unirritating  antiseptic  urethral  irrigations. 


CHAPTER  XX 

PSYCHOPATHIA  SEXUALIS 

The  various  forms  of  perversion  or  aberration  of  the  sexual  instinct  are, 
as  a  rule,  associated  with  symptoms  which  belong  to  the  domain  of  the  neurol- 
ogist or  the  alienist.  But  some  of  them  have  a  physical  basis  which  demands 
attention  from  the  geni to-urinary  specialist,  who  is,  at  any  rate,  apt  to  be  first 
consulted  in  many  such  cases.  Moreover,  the  distinction  between  a  pure  neu- 
rosis and  one  dependent  upon  lesions  often  requires  the  judgment  of  an  expert, 
based  upon  a  thorough  examination  of  the  genital  tract.  It  seems  proper, 
therefore,  to  present  a  brief  summary  of  the  chief  varieties,  and  to  give  at  least 
a  resume  of  the  general  principles  which  should  apply  in  dealing  with  these 
patients.  The  works  of  Krafft-Ebing  and  Schrenck-Notzing  have  been  used 
freely  in  the  preparation  of  this  chapter. 

An  accurate  and  entirely  scientific  classification  of  these  phenomena  is  at 
present  impossible,  but  a  provisional  one  may  be  employed,  which  will  aid  in 
the  systematic  study  of  the  subject. 

Nearly  all  the  known  varieties  of  sexual  perversion  will  fall  under  one  or 
other  of  the  following  headings: 

A.  Sexual  Hyperesthesia. 

1.  Onanism. 
i  Satyriasis. 
■  (  Nymphomania. 

B.  Sexual  Anesthesia. 

Impotence.    (See  Chapter  XIX.) 

C.  Sexual  Paresthesia. 

1.  Heterosexual    perversion — algolagnia.     Perverse    activity    of    the 

sexual  impulse. 

2.  Inversion  of  the  sexual  feeling  (contrary  sexual  feeling;  homosex- 

uality, etc.). 

SEXUAL  HYPER^^STHESIA 

When  not  dependent  on  affections  of  the  cord  or  on  cerebral  disease,  this 
is  usually  associated  with  hyperaesthesia  of  the  deep  urethra.  This  in  its  turn 
may  be  caused  by  masturbation  when  practised  in  great  excess,  by  urethral 
stricture,  by  chronic  infection,  by  sexual  intemperance  (which  term  should  in- 
clude both  excessive  intercourse  and  prolonged  sexual  excitement  without  relief, 
and  by  departure  from  the  normal  or  physiological  in  the  performance  of  the 
act  of  copulation  (as,  for  example,  the  practice  of  withdrawal  for  the  prevention 
of  conception).     Certain  drugs  produce  it,  cantharides  being  the  best  known. 

Onanism  is  the  common  expression  of  sexual  hyperaesthesia,  a  majority  of 
males  having  at  some  time  in  their  lives  practised  it.  Its  alleged  consequences 
are  used  by  quacks  to  foster  the  miseries  of  the  sexual  hypochondriac,  who, 

455 


456  GENITO-URINARY  SURGERY 

having  almost  alwa3"S  been  a  masturbator  to  some  extent  during  his  youth,  is 
easily  led  to  believe  that  he  has  thus  done  himself  serious  injury.  Von  Schrenck- 
Notzing,  in  reply^  to  the  argument  that  the  single  act  of  masturbation  is  no  more 
harmful  than  that  of  normal  coitus,  says  that  masturbation  has  a  much  more 
intense  psychical  effect  than  sexual  intercourse,  as  the  content  of  ideas  in 
every  onanistic  act  must  overcome  reality,  and  thus  a  much  more  intense  strain 
of  the  imagination  is  necessary.  He  adds,  however,  that  "  masturbation  mod- 
erately practised  exercises  on  a  good  constitution  no  direct  destroying  effect, 
but  it  changes,  when  it  is  long  indulged  in,  the  character,  the  imagination,  and 
the  whole  mental  existence  in  a  way  that  is  unmistakable  and,  so  to  speak, 
necessary.  These  e\dl  effects  of  onanism  seem  to  us  to  be  greater  than  those 
lesser  disturbances  which  seldom  affect  materially  the  general  health." 

A  long  hst  of  local  disorders  following  excesses  in  onanism  is  to  be  found 
in  the  abundant  literature  of  the  subject.  Lowenfeld  (quoted  by  Schrenck- 
Xotzing)  says  that  in  the  male  the  most  frequent  results  are  "  excessive  pol- 
lutions (day  and  night),  spermatorrhoea,  premature  ejaculation  in  attempt  at 
coitus,  hypersesthesia  of  the  genital  centres,  spinal  neurasthenia,  congestion 
of  the  prostate,  inflammation  of  the  urethra,  hyperaemia  and  swelling  of  the 
mucous  membranes,  and  intense  sensitiveness  of  the  glans.  In  young  children, 
besides,  there  may  readily  occur  vesical  tenesmus,  wetting  of  the  bed,  spasm 
of  the  compressor  urethrae,  and  urinary  incontinence."  Further  results  are 
urethritis,  prostatorrhoea,  spermatorrhoea,  and  impotence.  As  secondary  results 
of  the  neurosis  of  the  lumbar  portion  of  the  cord  he  mentions  "  general  neuras- 
thenia, tachycardia,  pains  in  the  eyelids,  spasm  of  the  lids,  photophobia,  or 
subjective  sensations  of  light,  diminution  of  the  acuity  of  central  vision,  neu- 
rasthenic asthenopia." 

In  the  female  masturbation  is  said  to  produce  neurasthenic  disturbances, 
such  as  hysterical  attacks,  paralyses  (vesical  paralysis),  vesical  tenesmus  and 
spasm,  ovarian  neuralgia,  weakness  of  the  legs,  and  spinal  irritation.  Among 
alleged  local  disturbances  may  be  mentioned  hypersemia  of  the  labia  minora 
and  the  vaginal  orifice,  desquamation  of  the  vaginal  epithelium,  cervical  catarrh, 
intense  hypersesthesia,  pruritus  vulvae,  hypertrophy  of  the  clitoris,  and  irritable 
conditions  of  the  uterus  and  adnexa.  Schrenck-Notzing  says  that  "  a  condition 
that  has  thus  far  been  too  little  studied,  and  which  in  its  significance  is  one  of 
the  most  important  and  frequent  results  of  masturbation  in  the  female,  is  a  form 
of  impotence  in  which  the  orgasm  no  longer  occurs  during  the  sexual  act,  even 
when  it  is  performed  with  several  men,  but  in  many  cases  may  be  induced 
post  coitum  by  masturbation." 

In  both  sexes  the  act  of  masturbation,  while  unquestionably  exercising  a 
prejudicial  influence  on  the  general  character  on  account  of  the  sense  of  wrong- 
doing almost  invariably  accompanying  it  and  the  atmosohere  of  secrecy  and 
deceit  which  necessarily  surrounds  it,  cannot  in  normal  individuals  be  accredited 
with  more  than  a  very  small  proportion  of  the  evils  said  to  follow  in  its  wake. 

In  neuropathic  children  of  adolescents,  the  inheritors  of  depraved  nervous 
systems  or  of  vicious  impulses,  it  is  no  doubt  far  more  injurious,  but  even  in 
them  it  is  open  to  question  whether  it  is  a  cause  or  a  svmptom  of  the  associated 
nervous  phenomena.    An  investigation  made  by  one  of  the  writers  showed  that 


PSYCHOPATHIA  SEXUALIS  457 

the  men  who  had  become  onanists  in  a  criminal  population  of  eight  hundred 
were  classified  either  as  the  subjects  of  mental  or  physical  disease  at  the  time 
of  their  admission  to  prison  or  as  hereditarily  predisposed  to  such  disease  in  the 
proportion  of  eighty-five  per  cent.  Among  the  remainder  of  the  eight  hundred 
only  fifty-eight  per  cent,  were  so  classified.  So,  too,  it  was  found  that  fifty-six 
per  cent,  of  the  masturbators  had  been  guilty  of  one  or  another  of  the  so-called 
"  crimes  of  the  passions  " — as  distinguished  from  crimes  against  property — 
while  a  review  of  the  records  for  fifty  years  showed  that  only  thirteen  per 
cent,  of  the  whole  number  of  convicts  had  been  convicted  of  crimes  of  this 
character.  The  evidence,  therefore,  goes  to  show  that  masturbation  in  great 
excess  is  itself  a  symptom  rather  than  a  cause  of  the  various  nervous  phenomena 
attributed  to  it. 

As  to  the  ordinary  form  of  masturbation,  so  common  as  almost  to  be  called 
physiological,  Sir  James  Paget  said  twenty-five  years  ago  "  you  may  teach 
positively  that  masturbation  does  neither  more  nor  less  harm  than  sexual  inter- 
course practised  with  the  same  frequency  with  the  same  conditions  of  general 
health  and  age  and  circumstance.  Practised  frequently  by  the  very  young — - 
that  is,  at  any  time  before  or  at  the  beginning  of  puberty — masturbation  is 
very  likely  to  produce  exhaustion,  effeminacy,  over-sensitiveness,  and  nervous- 
ness, just  as  equally  frequent  copulation  at  the  same  age  would  probably  pro- 
duce them.  Or,  practised  every  day,  or  many  times  in  one  day,  at  any  age, 
either  masturbation  or  copulation  is  likely  to  produce  similar  mischiefs  or 
greater.  And  the  mischiefs  are  especially  Hkely  or  nearly  sure  to  happen,  and 
to  be  greatest,  if  the  excesses  are  practised  by  those  who,  by  inheritance  or 
circumstances,  are  liable  to  any  nervous  disease,  to  '  spinal  irritation,'  epilepsy, 
insanity,  or  any  other  neurosis.  But  the  mischiefs  are  due  to  the  quantity,  not 
to  the  method,  of  the  excesses;  and  the  quantity  is  to  be  estimated  in  relation 
to  age  and  the  power  of  the  nervous  system."  He  has  seen  as  numerous  and 
as  great  evils  consequent  on  excessive  sexual  intercourse  as  to  excessive  mas- 
turbation ;  but  he  has  not  seen  or  heard  anything  to  make  him  believe  that  occa- 
sional masturbation  has  any  other  effects  on  one  who  practises  it  than  has 
occasional  sexual  intercourse,  or  anything  justifying  the  dread  with  which  sexual 
hypochondriacs  regard  having  occasionally  practised  it. 

Treatment  of  Onanism  in  Children. — In  the  absence  of  inherited  neu- 
ropathy, onanism  in  very  young  children  is  usually  an  automatic  act,  resulting 
from  some  persistent  local  irritation. 

Phimosis,  balanitis,  vesical  calculus,  and  urethral  polyp  are  common  causes 
of  sexual  excitation  in  male  children,  producing  the  custom  of  handling  or 
pulling  at  the  penis,  which  after  a  time  results  in  a  fully  formed  onanistic  habit. 

Masturbation  in  young  female  children  is  far  less  common  than  in  males. 
Eczema  and  pruritus  vulvae,  seat-worms,  and  other  causes  of  irritation  about 
the  genitals  or  the  anus  are  the  common  etiological  factors. 

In  both  sexes  irritation  from  diapers  or  from  tightly  fitting  clothing  may 
favor  the  continuance  of  the  habit. 

Obviously  the  treatment  of  such  cases  is  to  be  directed  towards  the  removal 
of  the  cause.  Circumcision  should  be  performed,  regardless  of  the  condition 
of  the  foreskin,  in  all  children  who  have  this  habit. 


458  GENITO-URINARY  SURGERY 

Even  if  it  is  not  very  long  or  tightly  adherent,  its  removal  lessens  the 
sensitiveness  of  the  glans  and  the  fraenum.  The  psychical  effect  of  the  opera- 
tion itself,  if  the  child  is  three  or  four  years  of  age  or  older,  has  a  powerful 
deterrent  influence.  Vesical  calculi  should  be  removed,  eczema  cured,  and  the 
other  pathological  conditions  mentioned  should  receive  appropriate  treatment. 

Intelligent  parents  can  be  of  great  assistance  in  breaking  up  the  habit.  The 
individual  management  of  the  child  must  be  determined  by  his  peculiarities 
of  disposition  and  temperament.  With  some  children,  even  while  they  are 
very  young,  a  few  words  of  caution  or  advice  are  effectual.  With  others  some 
form  of  punishment  is  required.  Occasionally  it  may  be  necessary  to  apply  a 
vesicant  -to  the  genitals,  thus  leaving  a  denuded  spot  which  will  be  painful 
enough  to  prevent  handling  of  the  part. 

Attention  should  be  paid  to  the  condition  of  the  urine.  An  excess  of  uric 
acid,  oxaluria,  a  very  acid  or  concentrated  urine,  may  furnish  the  necessary 
stimulus  to  the  performance  of  the  act. 

The  diet,  especially  the  evening  meal,  should  be  light  and  simple.  Con- 
stipation should  be  carefully  avoided.  An  enema  of  cold  water  at  bedtime, 
followed  by  the  insertion  of  a  white  wheat  gluten  suppository  into  the  rectum, 
will  often  be  found  of  advantage. 

Open-air  exercise  to  the  point  of  fatigue  is  indicated  in  the  majority  of 
cases.  Drugs  should  be  avoided.  Hand-guards  and  constant  supervision  are 
needed  in  some  instances. 

Treatment  of  Onanism  in  Adolescents  and- Adults. — In  all  cases  of  per- 
sistent masturbation,  at  whatever  age,  the  same  general  line  of  treatment  as 
that  outlined  above  should  be  followed.  The  conditions  that  are  provocative 
of  the  act  in  young  children  may  cause  its  continuance  after  puberty.  In  males 
circumcision  is  especially  to  be  recommended,  the  patient  being  told  that  the 
operation  is  necessitated  by  his  previous  indulgence  in  the  vice,  and  that  it  will 
prove  curative.  Cold  bathing,  a  simple  natural  life,  a  plain  diet,  plenty  of 
exercise,  and  avoidance  of  sexual  excitements,  are  the  main  points  to  be  observed 
as  to  the  hygiene  of  such  patients. 

The  use  of  full-sized  cold  steel  sounds  introduced  twice  weekly,  and  left  in 
the  urethra  for  from  ten  to  fifteen  minutes,  instillations  of  fifteen  to  twenty 
drops  of  a  one  per  cent,  silver  nitrate  solution  into  the  prostatic  urethra,  and 
counter-irritation  to  the  perineum,  are  at  times  serviceable  therapeutic  measures. 

As  to  the  general  advice  to  be  given  such  patients  in  regard  to  their  sexual 
relations,  while  we  agree  with  those  who  think  it  improper  to  advise  fornication, 
and  believe  it  is  inadvisable  to  recommend  marriage  as  a  mode  of  treatment, 
yet  we  must  dissent  from  the  opinions  which  have  been  expressed  by  many 
of  the  most  distinguished  men  in  the  profession  as  to  the  universal  harm- 
lessness  of  enforced  chastity.  Sexual  abstinence,  when  entirely  voluntary  and 
spontaneous,  and  practised  without  thought  or  mental  struggle  on  the  part  of 
the  patient,  is  doubtless  harmless.  But  it  seems  so  equally  beyond  doubt  that 
the  continence  which  is  the  result  of  fear  of  wrong-doing  or  of  dread  of  social 
disgrace  or  of  physical  disease,  and  which  is  attended  with  continued  sexual 
excitation  and  constant  hypergemia  of  the  genital  organs,  is  ultimately  harmful. 
It  does  not  follow  that  a  remedy  can  be  suggested.    Moreover,  the  evils  which 


PSYCHOPATHIA  SEXUALIS  459 

certainly  result  from  continence  in  individual  cases  are  far  less  than  those 
which  would  result  from  promulgation  of  the  doctrine  that  "  the  idea  of  com- 
plete health  includes  complete  and  regular  satisfaction  of  all  the  needs  of  man, 
and  that  is  the  goal  for  which  hygiene  must  strive,  and  not  seek  to  stifle  one 
of  the  most  important  functions  of  the  organism,  like  the  sexual  instinct.  The 
recommendation  voluntarily  to  destroy  any  function  like  the  idea  of  love  is  a 
subject  for  the  fanatic,  but  directly  opposed  to  hygiene."    (Tarnowsky.) 

Von  Schrenck-Notzing,  writing  of  prostitution,  says,  "  The  limitation  of 
the  evil  to  a  minimum,  which  seems  to  everyone  of  any  knowledge  of  the 
subject  both  desirable  and  attainable,  with  any  prospect  of  relative  success, 
can  only  be  brought  about  through  an  inner  reform  of  society;  through  cor- 
rect education  of  the  young  and  ignorant;  and  through  an  increase  of  facility 
of  marriage  and  amelioration  of  conditions  of  life.  '  For  the  more  undeveloped 
an  individual  is,  the  more  reckless  he  is  in  the  gratification  of  his  desires,'  We 
should  institute  a  real  sexual  education,  and  lead  the  matured  sexual  instinct 
by  means  of  the  preservation  of  rational  indulgence  into  paths  devoid  of  danger ; 
we  should  make  needful  concessions  to  the  natural  impulse;  and  thus  public 
vice,  with  its  results,  the  unlimited  spread  of  venereal  diseases  and  the  increasing 
number  of  crimes  against  morality,  would  be  greatly  diminished  and  become 
more  and  more  confined  to  the  step-children  of  nature  (those  subject  to 
congenital  viciousness) .  But,  more  than  all,  the  foundation  would  be  removed 
upon  which  rest  masturbation  and  the  development  of  the  sexual  instinct  in 
perverse  directions." 

Continuing,  he  adds,  "  The  strength  and  intensity  of  the  sexual  instinct, 
like  moral  and  physical  individuality,  are  too  various  to  make  it  necessary  to 
give  a  general  application  to  the  foregoing  statements.  Such  a  misunderstanding 
might  become  a  welcome  license  and  cloak  for  all  possible  expression  of  vice,  and 
it  would  open  the  door  to  sensuality.  While  one,  thanks  to  the  inherent 
peculiarities  of  his  organization,  can  easily  practise  abstinence,  another  is  led 
to  onanism,  and,  as  a  result  of  it,  is  utterly  ruined  if  he  has  no  opportunity 
for  natural  sexual  indulgence." 

The  patients  "  utterly  ruined  "  by  onanism  are  very  few,  but  it  must  be 
admitted  that  even  in  the  cases  in  which  it  is  a  symptom  rather  than  a  cause 
of  disease  normal  sexual  relations  are  greatly  to  be  desired  for  the  patient. 

In  the  present  constitution  of  society  individuals  must  suffer.  We  cannot 
follow  either  in  theory  or  in  practice  the  further  teaching  of  Notzing,  who 
says,  "  The  chaste  youth  should  exercise  sexual  abstinence  as  long  as  he  is 
able  to  restrain  the  instinct  without  injury  to  his  health.  Should  he  be  in 
danger,  owing  to  increasing  strength  of  his  sexual  impulse,  of  onanism,  of  falling 
a  victim  to  satyriasis  or  perverse  sexual  indulgence,  then  it  becomes  the  duty 
of  his  teacher  and  his  physician  to  cause  indulgence  in  coitus,  and  also  to 
acquaint  the  neophyte  with  precautionary  measures  which  will  guard  against 
excesses,  infection,  and  the  procreation  of  illegitimate  offspring,  which,  under 
certain  circumstances— e.g'.,  with  contrary  sexuality — may  be  hereditarily 
tainted.  Individual  sexual  capabilities  should  determine  the  frequency  of  sexual 
indulgence.    It  is  impossible  to  fix  a  normal  standard." 

It  is  not  customary  in  this  country  to  give  advice  of  this  character,  and 


460  GENITO-URINARY  SURGERY 

the  resultant  evils,  if  this  should  become  a  common  professional  practice,  would 
far  outweigh  the  advantages.  The  contrary  teaching  as  to  the  invariable  harm- 
lessness  and  even  benefit  of  sexual  continence  is  unscientific,  and  is  opposed  to 
many  easily  observed  clinical  phenomena. 

Satyriasis  and  Nymphomania. — In  these  cases  the  sexual  desire  is  so  over- 
powering that  its  gratification  becomes  the  one  dominant  thought  and  purpose 
of  the  patient's  life.  The  condition  may  be  spasmodic  with  remissions,  or,  in 
bad  cases,  may  be  almost  continuous.  It  is  favored  by  any  form  of  genital  irrita- 
tion, but  the  essential  factor  is  some  cerebral  disturbance  or  degeneration  which 
results  in  a  diminution  or  abolition  of  the  will-power.  Magnan  locates  these 
lesions  in  the  sensory  regions  of  the  cortex  which  lie  behind  the  central  con- 
volutions, where,  according  to  this  author,  "  the  zone  of  the  desires  and  instincts 
lies,  and  which  are  influenced  quasi-automatically  by  the  genitOTspinal  centre 
as  soon  as  the  forebrain  for  any  reason  ceases  to  act." 

It  may  in  some  cases  be  a  reversion  to  ancestral  instincts.  In  many  of  the 
lower  animals  during  the  rutting  season  the  sexual  impulse  becomes  so  powerful 
as  to  dominate  all  other  desires  and  habits  and  render  the  individual  insensible 
to  dangers  ordinarily  carefully  avoided. 

Women  are  said  to  be  more  subject  to  this  form  of  sexual  perversion  than 
are  men.  Whether  this  is  true  or  not,  there  can  be  no  doubt  that,  since  women, 
have  less  sexual  need  than  men,  a  predominating  sexual  desire  in  them  should 
arouse  more  early  a  suspicion  of  its  having  some  pathological  significance. 

Krafft-Ebing  says  that  "  the  central  origin  of  sexual  excitement  is  of  fre- 
quent occurrence  in  persons  having  a  neurotic  taint  or  hysteria,  and  in  conditions 
of  psychical  exaltation.  Here,  where  the  cortex  and  the  psycho-sexual  centre 
are  in  a  condition  of  hyperaesthesia  (abnormal  excitability  of  the  imagination, 
increased  ease  of  association),  not  only  visual  and  tactile  impressions,  but  also 
auditory  and  olfactory  sensations,  may  be  sufficient  to  call  up  lascivious  con- 
cepts." 

Magnan  reports  the  case  of  a  young  woman  who  had  an  increasing  sexual 
desire  from  puberty,  and  satisfied  it  by  masturbation.  Gradually  she  grew 
to  become  sexually  excited  at  the  sight  of  any  man  pleasing  to  her,  and,  since 
she  was  unable  to  control  herself,  she  would  sometimes  shut  herself  up  in  a  room 
until  the  storm  had  passed.  At  last  she  gave  herself  up  to  men  of  her  choice, 
that  she  might  get  rest  from  her  tormenting  desire;  but  neither  coitus  nor 
masturbation  brought  relief,  and  she  went  to  an  asylum. 

The  case  is  added  of  a  mother  of  five  children,  who,  in  despair  about  her 
inordinate  sexual  impulse,  attempted  suicide,  and  then  sought  an  asylum.  There 
her  condition  improved,  but  she  never  trusted  herself  to  leave  it. 

It  is  obvious  that  in  such  patients  the  sexual  symptoms  are  only  part  of 
a  general  disease,  probably  cerebral  in  almost  every  instance. 

They  are  acute  manifestations  of  a  more  or  less  chronic  degenerative  process, 
which  later  will  nearly  always  show  itself  by  some  form  of  paresis  or  paralysis, 
or  by  mania  or  dementia. 

Krafft-Ebing  says,  "  There  are  also  cases  that,  not  without  reason,  might  be 
called  chronic  satyriasis  or  nymphomania.  To  these  belong  the  men  who,  for 
the  most  part  as  a  result  of  abusus  veneris,  or  more  particularly  of  masturbation, 


PSYCHOPATHIA  SEXUALIS     .  461 

suffer  with  neurasthenia  sexuaHs,  and  at  the  same  time  have  intense  libido 
sexuahs.  The  imagination^  as  in  acute  cases,  is  in  a  state  of  excitement  and  the 
mind  full  of  obscene  images,  so  that  the  most  elevated  ideas  are  besmirched  with 
the  most  cynical  images  and  thoughts.  The  thought  and  desire  of  such  men  are 
solely  directed  to  the  sexual  sphere;  and  since  their  flesh  is  weak,  led  on  by 
their  fancy,  they  come  to  indulge  in  the  grossest  perversions  of  the  sexual  act. 
Analogous  cases  in  women  may  be  called  chronic  nymphomania.  They  naturally 
lead  to  prostitution." 

In  all  these  cases  the  genito-urinary  surgeon  may  be  of  use  in  removing  every 
source  of  peripheral  irritation,  an  important  element  of  treatment,  as  it  renders 
more  easy  a  restoration  of  the  balance  between  desire  and  will-power. 

SEXUAL  ANESTHESIA 

In  men  the  ordinary  forms  of  impotence,  or  inability  to  perform  the  sexual 
act,  are  among  the  manifestations  of  sexual  anaesthesia,  and  are  described  in 
Chapter  XIX. 

The  corresponding  forms  of  impotence  in  women  are  less  frequent,  so  far 
as  the  profession  has  any  reliable  knowledge  of  the  subject.  The  most  common 
variety  is  said  to  be  that  in  which  failure  of  the  female  to  secure  orgasm 
during  the  sexual  act  is  owing  to  premature  ejaculation  on  the  part  of  the 
male — premature,  that  is,  in  relation  to  the  woman's  requirements.  This 
appears  to  be  due  in  a  large  proportion  of  cases  to  a  degree  of  sexual  coldness 
which  is  not  overcome  by  the  ordinary  mechanical  excitation  of  the  parts,  and 
may  result  from  either  physical  or  psychical  conditions. 

Among  the  former  is  to  be  noted  disproportion  between  the  genital  organs 
of  the  two  individuals,  as  in  cases  of  abnormally  small  development  on  the 
part  of  the  male  or  of  unusually  large  and  relaxed  genitalia  on  that  of  the 
female.  Exhaustion  of  the  sexual  centre  from  long-continued  uterine  or  ovarian 
irritation,  neurasthenia,  and  vaginismus  should  also  be  mentioned.  Emotional 
conditions  are  among  the  chief  psychical  causes  of  impotence  in  the  female — the 
fear  of  pregnancy,  or  of  disease,  or  of  discovery,  when  the  intercourse  is  illegiti- 
mate; the  lack  of  affection,  or  of  some  of  the  sentimental  concomitants  of  the 
act,  when  it  is  performed  maritally. 

It  is  obvious  that  in  the  management  of.  these  cases  the  tact  and  intimate 
personal  knowledge  of  the  regular  medical  attendant  are  likely  to  be  of  far 
more  use  than  any  surgical  or  gynaecological  procedures,  which  must  be  limited 
to  the  removal  of  obvious  sources  of  irritation  and  of  any  mechanical  impedi- 
ments to  intercourse. 

The  foregoing  conditions  barely  fall  within  the  limits  of  sexual  psychopathy, 
but  there  are  more  marked  examples  of  sexual  anaesthesia  in  both  sexes  in 
which  the  absence  of  sexual  instinct  seems  to  be  absolute  and  to  depend  upon 
central  causes.    • 

Krafft-Ebing  says  that  these  functionally  sexless  individuals  are  seldom  seen, 
and  are,  indeed,  always  persons  having  degenerative  defects,  and  in  whom  other 
functional  cerebral  disturbances,  states  of  psychical  degeneration,  and  even 
anatomical  signs  of  degeneration,  are  observed.     With  such  patients  there  is 


462  GENITO-URINARY  SURGERY 

even  less  opportunity  for  treatment,  which  should  in  any  event  be  directed  by 
the  neurologist  or  alienist. 

SEXUAL  PARESTHESIA 

In  all  its  forms  this  condition  involves  a  perversion  of  the  sexual  ideas  with 
relation  to  the  individual.  The  perversion  may  be — 1,  heterosexual,  with 
abnormal  and  distorted  activity  of  the  sexual  impulse,  or,  2,  homosexual. 

1.  Algolagnia  {algos,  pain;  lagnos,  lust). — In  the  heterosexual  varieties 
of  the  disease — i.e.,  those  in  which  an  inclination  to  intercourse  with  the  opposite 
sex  exists — the  perversion  may  take  the  form  of  associating  acts  of  cruelty  and 
violence  with  the  act  of  coitus.  When  such  acts  are  directed  by  the  patient 
against  another  person  the  disease  is  known  as  sadism  (active  algolagnia).  This 
is  not  infrequent,  especially  with  males.  It  is  explained  on  the  theory  that 
the  two  emotions  of  lust  and  anger  both  throw  the  psychomotor  sphere  into  a 
state  of  extreme  excitation,  causing  an  impulse  to  react  in  every  possible  way  on 
the  object  that  supplies  the  stimulus.  In  neuropathic  individuals  this  impulse 
becomes  uncontrollable  and  leads  to  mutilation  or  murder.  The  disease  is  more 
frequent  in  males  because  to  them  belongs  the  aggressive  role  in  sexual  life,  and 
their  sexual  relations  have  always  involved  the  overcoming  of  obstacles.  In 
the  presence  of  pathological  conditions  this  aggressiveness,  usually  physiological, 
becomes  uncontrollable  and  leads  to  various  monstrous  and  unnatural  crimes. 

The  Whitechapel  murderer  is  in  all  probability  an  example  of  the  most 
extreme  form  of  sadism.  A  minor  form  is  illustrated  by  one  of  Tamowsky's 
cases.  The  patient  was  a  physician  of  neuropathic  constitution  reacting  badly 
to  alcohol.  Under  ordinary  circumstances  capable  of  normal  coitus,  as  soon 
as  he  indulged  in  wine  he  found  that  his  increased  desire  was  no  longer  satisfied 
by  simple  coitus.  In  this  condition  he  was  compelled  to  prick  the  nates  puellae 
or  to  make  stabs  with  the  lancet,  to  see  blood  and  feel  the  entrance  of  the  blade 
into  the  living  body,  in  order  to  have  ejaculation  and  experience  complete 
satiety  of  his  lust. 

Cases  exemplifying  a  great  variety  of  forms  of  sadism  have  been  published 
in  detail.  They  differ  only  in  degree  from  those  in  which  the  abnormal 
impulse  is  satisfied  by  biting,  scratching,  or  light  flagellation  to  those  in  which 
the  patient  becomes  a  veritable  monster,  sucking  the  blood  or  eating  the  flesh 
of  his  victim. 

Masochism  (passive  algolagnia)  is  the  converse  of  sadism.  The  abnormal- 
ity manifests  itself  in  a  desire  to  suffer  and  be  subjected  to  violence  and  cruelty. 
It  might  be  expected  that  for  similar  physiological  reasons  to  those  which  explain 
the  greater  frequency  of  sadism  in  males,  masochism  would  be  found  far  more 
frequently  in  females,  whose  normal  instincts  lead  towards  sexual  subjugation 
and  submission.  But  except  in  very  rare  instances  the  restraints  of  custom 
and  of  modesty  have  been  sufficient  to  prevent  women  from  giving  noticeable 
expression  to  this  form  of  sexual  perversion,  which  probably  often  constitutes 
an  unobserved  stage  of  mental  disorder  shown  later  in  other  ways. 

"  Inmasochism  there  is  also  a  graduation  of  the  acts  from  the  most  repulsive 
and  monstrous  to  the  silliest,  in  accordance  with  the  degree  of  intensity  of  the 
perverse  instinct,  and  the  power  of  the  remnants  of  moral  and  aesthetic  motives 


PSYCHOPATHIA  SEXUALIS  463 

that  oppose  it.  The  ultimate  consequences  of  masochism,  however,  are  opposed 
by  the  instinct  of  self-preservation,  and  therefore  murder  and  serious  injury, 
which  may  be  committed  in  sadistic  excitement,  have  here,  as  far  as  known,  no 
passive  equivalent  in  reality ;  but  the  perverse  desires  of  masochistic  individuals 
may,  in  imagination,  attain  these  extreme  consequences."  (Krafft-Ebing.) 

Rousseau  appears  to  have  been  a  masochist,  and,  according  to  Lombroso, 
Baudelaire  belonged  in  the  same  class. 

2.  Homosexuality,  or  contrary  sexual  instinct,  is  a  form  of  sexual  parses- 
thesia  of  unknown  etiology  characterized  by  the  existence  of  sexual  desires  and 
instincts  exactly  opposite  to  those  appropriate  to  the  sex  to  which  the  patient 
belongs. 

"  In  so-called  contrary  sexual  instinct  there  are  degrees  of  the  phenomenon 
which  quite  correspond  with  the  degrees  of  predisposition  of  the  individuals. 
Thus,  in  the  milder  cases,  there  is  simple  hermaphroditism;  in  more  pronounced 
cases,  only  homosexual  feeling  and  instinct,  but  limited  to  the  vita  sexualis;  in 
still  more  complete  cases,  the  whole  psychical  personality,  and  even  the  bodily 
sensations,  are  transformed  to  correspond  with  the  sexual  perversion;  and  in 
the  complete  cases  the  physical  form  is  correspondingly  altered."  (Krafft- 
Ebing.) 

In  accordance  with  this  classification  the  same  author  describes  the  follow- 
ing varieties  of  the  disease: 

1.  Psychical  Hermaphroditism. — The  characteristic  mark  of  this  degree 
of  inversion  of  the  sexual  instinct  is  that,  by  the  side  of  the  pronounced  sexual 
instinct  and  desire  for  the  same  sex,  a  desire  towards  the  opposite  sex  is  present ; 
but  the  latter  is  much  weaker  and  is  manifested  episodically  only,  while  the 
homosexuality  is  primary,  and  in  time  and  intensity  forms  the  most  striking 
feature  of  the  vita  sexualis. 

It  is  thought  that  such  individuals,  on  account  of  neurasthenia,  of  masturba- 
tion, or  of  unfavorable  experiences  in  sexual  intercourse  with  persons  of  the 
opposite  sex  (lack  of  pleasure,  weakness  of  erection,  premature  ejaculation, 
infection,  etc.),  may  have  the  homosexual  instinct  strengthened,  and  after  satis- 
fying the  impulse  by  passive  or  mutual  onanism  with  a  person  of  the  same 
sex,  or  by  coitus  inter  femora,  may  pass  into-  the  second  group. 

2.  Urnings. — In  distinction  from  the  preceding  group  of  psychosexual 
hermaphrodites  there  are  here,  ab  origine,  sexual  desires  and  inclinations  for 
persons  of  the  same  sex  exclusively;  but,  in  contrast  with  the  following  group, 
the  anomaly  is  limited  to  the  vita  sexualis,  and  does  not  more  deeply  and 
seriously  affect  the  character  and  mental  personality.     (Krafft-Ebing.) 

The  patients  belonging  in  this  class  have  a  disgust  for  coitus  with  persons 
of  the  opposite  sex.  Their  affections  are  apt  to  be  emotional  and  passionate; 
they  present  all  the  phases  of  sentimental  attachment  to  persons  of  their  own 
sex  that  are  seen  in  normal  individuals  only  between  males  and  females.  They 
are  usually  unable  to  have  intercourse  successfully  in  a  normal  manner,  partly 
because  the  act  of  coitus  is  inhibited  by  their  emotional  condition.  In  men  of 
this  class  mutual  masturbation  and  often  pederasty  afford  sexual  gratification; 
in  women,  mutual  masturbation  in  one  form  or  another. 

3.  EfTemination  and  Viraginity. — In  this  class  not  only  the  sexual  in- 


464  GENITO-URINARY  SURGERY 

stincts  but  all  the  feelings  and  inclinations  are  reversed.  The  men  are  females 
in  habits,  sentiments,  and  character;  the  women,  males.  In  such  cases  hetero- 
sexual love  is  looked  upon  as  incomprehensible,  and  sexual  intercourse  with  a 
person  of  the  opposite  sex  as  impossible.  In  homosexual  intercourse  the  man 
always  feels  himself,  in  the  act,  as  a  woman;  the  woman,  as  a  man.  The  means 
of  indulgence,  in  the  case  of  a  man,  where  there  is  irritable  weakness  of  the  ejacu- 
lation centre,  are  simple  succubus,  or  passive  coitus  inter  femora;  in  other 
cases  passive  masturbation,  or  ejaculatio  viri  dilecti  in  ore  propria.  Many  have 
a  desire  for  passive  pederasty ;  occasionally  a  desire  for  active  pederasty  occurs. 
The  sexual  satisfaction  of  the  female  probably  consists  of  amor  lesbicus,  or  active 
masturbation. 

4.  Androgyny  and  Gynandry. — In  this  most  extreme  variety  of  homo- 
sexuality not  only  are  the  character  and  the  feelings  sexually  reversed,  but  also 
the  form,  the  features,  and  the  voice,  so  that  the  individual  approaches  the 
opposite  sex  anthropologically  and  in  more  than  a  psychical  and  psychosexual 
way.  This  anthropological  form  of  the  cerebral  anomaly  apparently  represents 
a  very  high  degree  of  degeneration;  but  that  this  variation  is  entirely  different 
from  the  teratological  manifestation  of  hermaphroditism,  in  an  anatomical  sense, 
is  clearly  shown  by  the  fact  that  thus  far  in  the  domain  of  contrary  sexuality 
no  transitions  to  hermaphroditic  malformation  of  the  genitals  have  been  ob- 
served. The  genitals  of  these  persons  always  prove  to  be  fully  differentiated 
sexually,  though  not  infrequently  there  are  present  anatomical  signs  of  degenera- 
tion (epispadiasis,  etc.),  in  the  sense  of  arrests  of  development  in  organs  that 
are  otherwise  well  differentiated.    (Krafft-Ebing.) 

The  works  so  freely  quoted  in  the  above  outline  of  sexual  psychopathy 
contain  many  suggestions  as  to  therapy.  The  most  important  of  these  relate 
to  the  prophylaxis  of  such  troubles  by  early  recognition  of  the  neuropathic  con- 
stitution, the  prevention  of  onanism,  and  the  encouragement  of  normal  or  hetero- 
sexual impulses  even  in  early  youth  by  regulating  the  sports  and  the  companions 
of  children.  Hypnotic  suggestion  is  being  extensively  tried  in  adult  cases, 
occasionally  with  excellent  results. 


CHAPTER  XXI 

SURGERY  OF  THE  BLADDER 

ANATOMY 

The  bladder,  when  normally  distended,  holds  about  one  pint  of  jEluid.  Pro- 
vided its  walls  are  healthy,  the  urine  may  be  retained  without  risk  of  injury  till 
twice  that  quantity  has  accumulated.  When  from  chronic  obstruction  there 
is  constant,  slowly  increasing  intravesical  tension,  the  bladder  may  become 
greatly  distended,  retaining  over  a  gallon  of  urine.  When  empty,  or  moderately 
distended,  the  bladder  lies  within  the  pelvis,  between  the  posterior  surface  of 
the  pubes  and  the  rectum.  As  it  fills,  its  upper  portion  rises  from  the  pelvis 
and  can  be  felt  on  abdominal  palpation,  since  it  tilts  forward  and  is  closely 
applied  to  the  belly- wall.  As  tension  increases,  the  upper  posterior  wall  bulges 
upward,  and  may  be  felt,  even  above  the  umbilicus. 

The  bladder  is  spoken  of  as  consisting  of  three  portions,  the  apex,  the  body, 
and  the  fundus,  or  base.  Of  these  the  apex  is  that  portion  in  the  region  of  the 
attachment  of  the  urachus,  or  ligamentum  umbilicale  medium;  the  fundus  or 
base  lies  below  a  plane  passing  through  the  points  of  entrance  of  the  ureters 
into  the  bladder  wall  and  the  urethral  orifice;  while  the  body  of  the  bladder 
is  that  portion  between  these  regions.  The  vesical  orifice,  the  lowest  portion 
of  the  bladder  in  the  erect  position,  is  placed  about  one  and  a  quarter  inches 
behind  and  slightly  below  the  middle  of  the  pubic  symphysis;  in  children,  this 
orifice  is  on  a  level  with  the  upper  border  of  the  symphysis,  the  bladder  in  them 
lying  much  higher  in  the  abdomen. 

The  upper  portion  of  the  bladder  is  freely  movable;  its  base  is  more  or 
less  fixed.  It  is  held  in  place  by  the  recto-vesical  fascia,  by  the  intimate  mus- 
cular and  fibrous  attachments  to  the  prostate,  by  the  urachus  and  the  obliterated 
hypogastric  arteries,  by  its  vascular  conneetions,  and  finally  by  ligaments  derived 
mainly  from  the  reflections  of  the  pelvic  fascia  (true  ligaments)  and  from  the 
peritoneum  (false  ligaments). 

The  urachus,  a  fibro-muscular  cord,  and  the  obliterated  hypogastric  arteries 
pass  from  the  summit  of  the  bladder  to  the  umbilicus.  The  expansions  of  the 
pelvic  fascia  hold  the  neck  and  base  of  the  bladder  in  position.  The  anterior 
or  pubo-prostatic  ligaments  from  either  side  of  the  lower  portion  of  the  pubic 
symphysis  fix  the  prostate  gland  and  the  anterior  part  of  the  bladder  neck; 
the  lateral  ligaments  embrace  the  prostate  and  the  lateral  border  of  the  bladder 
base.  The  false  ligaments  or  peritoneal  folds  are  the  superior,  covering  the 
urachus  and  the  obliterated  hypogastric  arteries  from  the  umbilicus  to  the 
vesical  apex,  the  lateral,  reflected  from  the  iliac  fossse  to  the  bladder  sides,  and 
the  posterior,  containing  the  ureters  and  hypogastric  arteries  and  bounding  the 
recto-vesical  fold. 

Peritoneal  Covering  of  the  Bladder. — The  peritoneal  covering  of  the 
urachus  and  the  obliterated  hypogastric  arteries  passes  directly  to  the  bladder, 
30  465 


466 


GENITO-URINARY  SURGERY 


investing  its  posterior  surfaces  from  the  apex  to  the  superior  extremities  of 
the  seminal  vesicles  and  the  vesical  extremities  of  the  ureters.  It  is  continued 
laterally  to  the  position  of  the  obliterated  hypogastric  arteries,  passing  back- 
ward as  it  descends  to  the  recto-vesical  cul-de-sac,  and  covering  a  portion  of  the 
vas  deferens.  Posteriorly,  the  peritoneum  is  reflected  from  the  bladder  to  the 
rectum,  forming  the  recto-vesical  pouch.  This  pouch  is  usually  more  than 
three  and  less  than  four  inches  from  the  anus;  exceptionally,  the  vesical  peri- 
toneum may  descend  as  far  as  the  prostate,  and  would  then  be  less  than  two 
inches  from  the  anal  orifice. 


Fig.  23  7. — Side  view  of  pelvic  viscera. 

When  the  bladder  is  empty  the  peritoneum  lining  the  anterior  ■beliy-wall 
descends  as  far  as  the  upper  border  of  the  pubis,  and  is  reflected  from  this  level 
to  the  vesical  apex.  As  the  bladder  becomes  distended  this  peritoneal  re- 
flection is  lifted  upward,  and  the  anterior  vesical  wall  becomes  accessible  to 
operation  by  suprapubic  incision  without  danger  of  entering  the  peritoneal 
cavity  (Fig.  237).  When  the  bladder  is  moderately  distended  and  is  further 
elevated  by  rectal  distention,  the  peritoneal  reflection  may  be  raised  two  inches 
above  the  upper  border  of  the  symphysis. 

Exceptionally  the  parietal  peritoneum  is  adherent  to  the  symphysis.  In 
this  case  a  suprapubic  cut  must  necessarily  open  the  general  abdominal  cavity. 
There  is  no  means  of  determining  the  presence  of  such  an  anomalous  condition 


SURGERY  OF  THE  BLADDER  467 

before  operation:  hence  the  danger  always  possible  in  suprapubic  puncture  or 
aspiration. 

Structure  of  the  Bladder. — The  mucous  membrane  of  the  bladder  is  made 
up  of  fiat  epithelium  based  upon  deep  layers  of  cylindrical  cells.  It  is  of  a 
pinkish  yellow  color,  exhibiting  plications  which  disappear  on  distention  of 
this  viscus.  In  the  trigonum  the  mucous  membrane  is  applied  directly  to  the 
subjacent  structure,  and  slight  papillary  outgrowths  are  sometimes  seen;  excep- 
tionally rudimentary  glands  are  found.  From  embryological  and  histological 
standpoints,  and  in  accordance  with  the  symptomatology  of  lesions  of  this  region, 
the  trigonum  is  to  be  regarded  as  a  part  of  the  urethra  rather  than  of  the  bladder. 

The  muscular  walls  of  the  bladder  are  arranged  in  three  layers.  The  outer 
longitudinal  layer  contributes  fibres  to  the  formation  of  the  anterior  vesical 
ligaments.  Through  or  between  these  musculo-tendinous  fasciculi  pass  the 
anterior  vesical  veins  to  join  the  plexus  of  Santorini.  The  middle  layer  is  com- 
posed of  circular  fibres  completely  covering  in  the  bladder.  These  are  thickest 
about  the  urethral  orifice,  forming  the  internal  vesical  sphincter.  The  inner 
layer  is  made  up  of  longitudinal  fibres  passing  from  the  apex  to  the  neck.  The 
fibres  composing  this  layer  are  grouped  in  bundles  or  fasciculi,  which  anasto- 
mose, forming  a  coarse  network  and  producing  the  characteristic  reticulation 
of  the  inner  surface. 

Vascularization  and  Innervation, — Blood  is  carried  to  the  bladder  by 
branches  of  the  internal  iliac  arteries.  These  are  the  superior  vesical,  supplying 
the  apex  and  the  lateral  surfaces  and  deferent  canals;  the  middle  vesical  supplying 
the  base  of  the  bladder  and  the  seminal  vesicles;  the  inferior  vesicals,  often 
from  the  middle  hemorrhoidal,  running  to  the  prostate,  the  seminal  vesicles,  and 
the  trigonum;  and  the  anterior  vesicals,  small  and  variable,  derived  from  the 
internal  iliac  or  the  obturator.  These  blood-vessels  penetrate  the  muscular  coats 
of  the  bladder,  forming  a  submucous  plexus  from  which  the  epithelial  capillaries 
are  given  off. 

The  veins  of  the  mucous  membrane,  having  penetrated  the  muscular  coat, 
form  a  superficial  plexus,  made  up  of  large,  freely  anastomosing,  valved  trunks, 
usually  running  longitudinally.  The  anterior  vesical  veins  pass  into  the  pubo- 
prostatic plexus  (plexus  of  Santorini),  situated  just  beneath  the  symphysis  to 
the  right  and  left  of  the  median  line;  the  lateral  veins,  particularly  voluminous 
and  numerous,  empty  into  the  vesico-prostatic  plexus.  The  posterior  veins,  also 
large,  pass  into  the  vesico-prostatic  plexus  or  seminal  plexus.  The  pubo- 
prostatic, the  vesico-prostatic,  and  the  seminal  plexus  anastomose  freely,  and 
practically  form  one  series  of  large  vessels,  which  is  emptied  by  all  the  veins 
lying  near  at  hand,  including  the  hypogastric,  the  ureteric,  the  hemorrhoidal, 
the  internal  pudic,  the  obturator,  and  the  spermatic. 

The  lymphatics  of  the  upper  two-thirds  and  lower  anterior  third  and  neck 
of  the  bladder  drain  into  the  external  iliac  ganglia,  those  of  the  posterior  third 
into  the  hypogastric  or  presacral  nodes. 

The  nerves  of  the  bladder  are  derived  from  the  hypogastric  plexus  and 
from  the  anterior  branches  of  the  third  and  fourth  sacral  nerves. 

General  Considerations.— At  the  bladder  base  lies  the  trigonum,  pre- 
senting a  smooth  red  surface,  in  the  form  of  a  nearly  equilateral  triangle,  each 


468  GENITO-URINARY  SURGERY 

side  of  which  is  about  one  and  a  quarter  inches  long.  The  angles  correspond 
in  position  to  the  internal  vesical  orifice  and  the  two  slight  projections  or  open- 
ings of  the  ureters.  The  triangle  may  be  distinctly  outhned  by  perceptible 
ridges  passing  between  the  two  ureteral  openings  and  from  these  to  the  internal 
vesical  orifice.  These  ridges  represent  a  reinforcement  of  the  vesical  ajnd  ureteral 
muscles,  designed  to  preserve  the  valve-iike  action  of  the  ureters  and  to  keep 
them  closed  against  back  pressure  from  the  bladder. 

The  trigonum  and  the  vesical  neck  are  more  abundantly  supplied  with  blood- 
vessels and  nerves  than  are  any  other  portions  of  the  bladder. 

It  follows  from  the  position  of  the  bladder  that  it  is  well  protected  from 
direct  traumatism,  and  that  it  is  accessible  to  exploration  by  combined  rectal 
and  suprapubic  palpation.  Its  abundant  blood-supply  assures  quick  healing  of 
surgical  or  accidental  wounds  when  other  conditions  favorable  for  healing  are 
present.  The  superficial  layers  of  flat  epithelium  with  which  the  mucous  mem- 
brane is  provided  insure  against  absorption  from  the  bladder  as  long  as  the 
epithelium  remains  healthy  and  unbroken,  thus  protecting  the  system  against 
poisoning  by  toxic  substances  eliminated  with  the  urine  and  guarding  the  tissues 
locally  against  infection.  The  loose  attachment  of  the  mucous  membrane  to 
the  underlying  muscular  tissues  and  the  arrangement  of  the  muscular  coat 
prevent  extravasation  of  urine  after  puncture  of  a  full  bladder,  the  opening,  on 
withdrawal  of  the  needle  or  trocar,  becoming  valvular  by  the  sliding  of  the 
tissues.  The  great  venous  plexus  at  the  base  of  the  bladder  and  the  many  large 
veins  passing  over  its  surface,  together  with  the  free  intercommuiiication  be- 
tween all  the  pelvic  veins,  explain  the  frequency  of  dangerous  venous  bleeding 
in  bladder  surgery.  These  facts  also  show  how  important  an  effect  upon  the 
bladder  is  exerted  by  any  cause,  such  as  constipation,  producing  pelvic  engorge- 
ment. The  particularly  generous  innervation  and  vascularization  of  the  trigo- 
num and  the  bladder-neck  explain  the  greater  pain  and  reaction  from  inflam- 
mation or  manipulation  of  this  part  of  the  viscus. 

MALFORMATIONS   AND   MALPOSITION   OF  THE  BLADDER 

The  bladder  may  be  multiple.  Its  walls  may  be  absent  in  whole  or  in 
part,  may  be  hypertrophied,  atrophied,  or  herniated.  The  urachus  may  remain 
patulous. 

Multiple  bladder,  in  the  true  sense  of  the  term,  is  an  extremely  rare 
deformity.  Usually  there  is  a  single  bladder  with  a  septum  running  fore  and 
aft  (Fig.  238)  or  obliquely  or  even  transversely.  The  ureters  open  into  the 
main  bladder  cavity.  More  frequently  it  is  a  sacculated  bladder.  Sometimes 
the  apparent  anomaly  is  due  to  the  enormous  dilatation  of  a  ureter. 

When  the  bladder  is  really  multiple,  as,  for  instance,  in  a  reported  case  in 
which  there  were  five  kidneys,  each  with  a  separate  receiving  viscus,  no  operative 
measure  is  indicated.  Sacculation,  with  attendant  cystitis  from  defect  of  drain- 
age, would  indicate  simply  the  treatment  of  the  cystitis.  Enormous  dilatation 
of  the  ureter,  if  it  could  be  diagnosed,  would  indicate  the  relief  of  the  stricture 
or  the  formation  of  a  new  opening  between  the  dilated  ureter  and  the  bladder. 

Complete  Absence  of  the  Bladder. — When  the  bladder  is  completely 
absent,  the  ureters  open  into  the  urethra,  the  vagina,  the  rectum,  or  at  the 


SURGERY  OF  THE  BLADDER 


469 


umbilicus.  The  condition  may  be  treated  by  the  appUcation  of  a  urinal,  which 
prevents  the  garments  from  being  soiled,  or  by  implantation  of  the  ureters 
into  the  bowel,  preserving  a  rosette  of  the  tissue  into  which  the  ureter  opens. 

Exstrophy 

Exstrophy  of  the  bladder  is  usually  observed  as  an  absence  of  the  anterior 
wall  (Fig.  239),  though  cases  are  reported  in  which  the  septum  separating  the 
bladder  from  the  vagina  or  the  rectum  has  been  absent.  It  is  commonest  in 
male  children,  and  is  due  to  the  failure  of  the  lateral  portions  of  the  uro-genital 


Fig.  238. — Multiple  fused  bladder.     The  two  bladders  communicate  by  a  small 
opening  denoted  by  the  probe.     (From  the  Mutter  Museum,   College  of  Physicians.) 

cleft  to  unite.  Hence  in  pronounced  cases  there  is  a  deficiency  not  only  in  the 
anterior  wall  of  the  bladder  but  also  in  the  musculo-cutaneous  abdominal  parietes 
and  the  pelvic  girdle,  the  pubes  not  meeting  in  the  middle  line  to  form  the  sym- 
physis, the  gap  sometimes  measuring  as  much  as  two  inches.  This  deformity 
is  associated  with  epispadia  in  the  male  and  split  clitoris  in  the  female,  the 
bladder  and  urethra  opening  in  the  female  either  into  the  vagina  or  just 
above  it. 

From  weakness  of  the  abdominal  parietes  there  is  commonly  associated  with 
this  deformity  complete  double  inguinal  hernia,  which,   descending  into  the 


470  GENITO-URINARY  SURGERY 

cleft  scrotum,  causes  its  two  halves  closely  to  resemble  the  labia  majora  of  the 
female.  The  prostate  is  rudimentary,  the  testicles  often  are  ectopic.  The 
seminal  vesicles  are  either  absent  or  are  greatly  atrophied.  The  ureters  are 
often  dilated,  and  sometimes  so  sharply  bent  that  conseqeunt  obstruction  and 
dilatation  occur.  In  the  female  the  greater  and  lesser  vulvar  lips  are  not  joined 
anteriorly,  and  the  clitoris  is  split,  the  vagina  being  converted  into  a  small 
channel.  The  recti  muscles  pass  upward  and  inward  on  either  side  from  their 
insertion  into  the  separated  pubis.  Sometimes  this  separation  is  continued 
upward  almost  to  the  origin  of  the  muscles,  allowing  the  formation  of  ventral 
hernia. 

On  examining  a  case  of  exstrophy  of  the  bladder  there  is  found  presenting 


f 


Fig.  239. — Exstrophy  of  the  bladder.      (From  Mutter  Museum,  College  of  Physicians  of  Philadelphia.) 

in  the  hypogastric  and  pubic  region  a  bulging,  moist,  dark  red  surface  of 
intensely  inflamed  rugous  mucous  membrane,  surrounded  by  an  area  of  cicatricial 
tissue,  uniting  its  borders  to  the  skin.  This  projection  varies  in  size  from  that 
of  a  half  walnut  in  infants  to  that  of  a  man's  fist  in  adults.  It  bleeds  readily, 
is  extremely  sensitive,  its  lower  portion  is  wet,  and  the  projections  marking  the 
ureteral  orifices  can  usually  be  found  by  the  escape  of  urine,  which  spirts  from 
them  in  jets.     This  tumefaction  may  extend  upward  as  far  as  the  umbilicus. 

Continuous  with  the  lower  border  of  the  mucous  surface  is  the  urethra, 
passing  as  a  furrow  on  the  dorsal  aspect  of  the  rudimentary^  penis,  the  prepuce 
of  which  forms  a  large  flap  hanging  from  the  under  surface  of  the  glans. 

Patients  exhibiting  this  deformity  are  usually  of  poor  physical  development 
in  other  respects,  and  often  perish  from  ascending  pyelonephritis.     As  a  result 


SURGERY  OF  THE  BLADDER 


471 


The  scar-tissue  surrounding 


of  the  leakage  of  urine  inseparable  from  exstrophy,  the  surrounding  skin  becomes 
infiltrated  and  excoriated,  and  erysipelas  sometimes  develops.  Sexual  desire  is 
generally  wanting,  though  in  the  female  this  deformity  does  not  necessarily  inter- 
fere with  coitus  and  parturition. 

Associated  deformities  are  by  no  means  uncommon.  At  times  the  intestine 
or  the  anus  opens  through  the  exstrophied  mucous  membrane.  Generally  the 
anus  is  placed  farther  forward  than  normal.  Spina  bifida  and  club-foot  may 
be  associated  with  exstrophy. 

In  degree  exstrophy  varies  from  the  slight  form  characterized  by  epispadia 
and  a  cicatricial  condition  of  the  skin  in  the  neighborhood  of  the  pubis,  to 
the  form  characterized  by  complete  hypogastric  fissure  with  eventration.  Be- 
tween these  extreme  degrees  of  exstrophy  there  is  every  gradation.  Heredity 
exerts  no  influence  in  causing  this  deformity. 

The  diagnosis  of  exstrophy  is  unmistakable 
the  mucous  membrane  is  congenital,  and  is 
not  due  to  previous  destructive  inflammation. 

The  prognosis  must  be  guarded,  since 
the  conditions  are  favorable  to  kidney- 
infection. 

Treatment  may  be  either  palliative  or 
radical.  Palliative  treatment  consists  in 
the  application  of  a  urinal  so  constructed 
that  a  hollow  rubber  cup  accurately  fits  the 
skin  surface  surrounding  the  cleft,  and  thus 
enables  the  urine  to  be  drained  off  into  a 
reservoir  (Fig.  240). 

Radical  operation  consists  in  closing  the 
defect  by  plastic  operations,  or  in  diverting 
the  ureters. 

The  most  successful  radical  operation 
can  never  make  a  satisfactorily  retentive  bladder,  since  a  sphincter  which  will 
be  under  proper  nervous  control  cannot  be  formed.  Plastic  operations  usually 
aim  to  lessen  deformity  and  to  close  the  bladder  sufficiently  to  allow  of  easy 
drainage  by  means  of  a  urinal,  thus  protecting  the  surrounding  skin  from 
irritation  and  enabling  the  patient  to  keep  himself  clean.  The  Roux-Wood 
operation  is  the  one  most  in  favor.  A  cutaneous  flap,  the  attachment  of  which 
corresponds  to  the  upper  border  of  the  cleft,  is  turned  down  from  above  the 
bladder.  This  flap  should  be  of  sufficient  length  to  cover  entirely  the  exposed 
mucous  membrane;  the  skin  surface  thus  forms  a  new  anterior  wall  for  the 
bladder.  The  lateral  borders  of  this  flap  are  sutured  with  catgut  to  the  freshened 
skin  borders  of  the  congenital  cleft.  There  is  thus  formed  a  pouch,  the  anterior 
wall  of  skin,  the  posterior  of  mucous  membrane.  The  raw  outer  surface 
of  this  first  flap  is  then  covered  in  by  two  lateral  rectangular  flaps  which 
have  their  attached  bases  placed  in  the  inguinal  region  of  each  side.  These 
two  flaps  are  made  of  such  length  that  without  undue  tension  they  can  be 
carried  transversely  across  the  raw  surface  of  the  first  flap,  covering  it  com- 
pletely.   The  free  borders  of  these  flaps  are  sewed  together  with  silkworm-gut. 


Fig.  240. — A,  day  urinal;  1,  detachable 
reservoir.  B,  night  and  day  urinal;  2,  detach- 
able reservoir. 


472  GENITO-URINARY  SURGERY       • 

tinally,  the  large  wound  resulting  from  the  transplantation  of  these  flaps  is 
closed  in  as  far  as  possible  by  means  of  silk  sutures. 

Closure  of  the  bladder  by  direct  suture  possesses  the  advantage  of  forming 
a  vesical  cavity  consisting  entirely  of  mucous  membrane.  When  there  is  bone- 
defect,  an  essential  point  in  successfully  performing  this  operation  is  the  approxi- 
mation of  the  two  pubic  bones.  This  may  be  accomplished  in  infants  by  sub- 
cutaneous symphyseotomy  of  the  sacroiliac  joints,  followed  by  forcible  lateral 
pressure  and  the  application  of  a  gravity  apparatus. 

Extraperitoneal  implantation  of  the  exstrophied  bladder  into  the  rectum  has 
been  successfully  performed  by  Moynihan,  the  organ  being  freed  except  for  the 
attachment  of  the  ureters,  inverted,  and  sutured  into  the  anterior  wall  of  the 
bowel. 

Maydl  has  successfully  accomplished  this  transplantation  by  opening  the 
peritoneal  cavity  at  the  border  of  the  exstrophied  bladder  and  removing  the 
whole  of  the  latter  except  a  small  segment  containing  the  ureteral  orifices.  Into 
the  ureters  are  passed  small  catheters.  The  small  bladder-segment  left,  together 
with  the  attached  ureters,  is  thoroughly  mobilized;  the  pelvic  colon  is  drawn 
out  and  incised  longitudinally,  and  in  this  opening  is  secured  the  portion  of 
the  bladder-wall  containing  the  ureters.  The  mucous  membrane  is  first  sewed 
to  the  mucous  membrane  of  the  gut,  then  the  musculo-peritoneal  coating  of  the 
intestine  is  sutured  to  the  muscular  wall  of  the  bladder-segment.  Finally  the 
abdominal  wound  is  closed  by  suture.  Orloff  collected  fifty-six  cases  of  Maydl's 
operation.  Eleven  cases  died  within  twenty-one  days  after  operation;  four 
from  peritonitis.  Of  the  forty-five  remaining  cases  only  five  died  of  the  later 
results  of  ascending  infection.  The  post-operative  complications  have  been  pneu- 
monia in  six  cases,  fecal  fistula  in  seven  cases,  phlebitis  of  the  leg  in  one. 
Some  renal  colic  and  albuminuria  were  noted  in  nearly  all.  There  is  little 
irritation  of  the  bowel  and  the  anal  sphincter  remains  competent. 

Peters  ^  describes  in  detail  an  excellent  method  of  implanting  the  ureters 
into  the  rectum  by  the  extraperitoneal  route. 

in  certain  appropriate  cases  the  method  of  choice  is  direct  suture  of  the 
freshened  bladder-borders,  thus  forming  an  irregular  cylinder,  which  acts  not  as 
a  reservoir  but  as  a  conductor,  of  urine,  allowing  a  portable  urinal  to  be  em- 
ployed. In  children  an  effort  should  be  made  to  close  the  bony  defect  by 
elastic  or  weight  pressure.  Symphyseotomy  is  by  no  means  free  from  danger. 
The  exact  value  of  this  procedure  and  the  additional  risk  inseparable  from  it 
remain  yet  to  be  determined.  When  successful,  it  enables  the  surgeon  to  close 
the  bladder  and  a  part  of  the  urethra  by  direct  suture. 

Ureteral  deviation  is  theoretically  the  most  satisfactory  immediate  treatment 
of  exstrophy,  but  its  mortality,  both  immediate  and  remote,  is  high. 

Before  any  operation  is  performed  the  inflamed  skin  surrounding  the  bladder 
must  be  rendered  healthy  by  cleansing  washes  and  healing  protective  salves. 
Thus,  twice  daily  the  parts  may  be  bathed  in  five  per  cent,  ichthyol  solution, 
followed  by  the  application  of  a  thick  zinc  paste,  made  by  adding  four  drachms 
of  finely  powdered  zinc  oxide  to  an  ounce  of  benzoated  zinc  ointment.  This 
paste  is  removed  by  rubbing  with  cosmoline. 

'  Canadian  Journal  of  Medicine  and  Surgery,  April,  1902. 


SURGERY   OF  THE  BLADDER  473 

Congenital  diverticulum  always  causes  hypertrophy  of  the  bladder-wall, 
and  ultimately  is  likely  to  exhibit  the  lesions  oi  intense  inflammation,  and  not 
infrequently  of  stone  formation.  The  most  pronounced  symptom  is  frequent 
urination,  which  later,  with  the  onset  of  inflammation,  may  be  painful.  There 
is  commonly  a  sensation  as  though  the  bladder  had  not  been  completely  evacu- 
ated, and  after  the  act  of  micturition  more  urine  can  usually  be  voided. 
Occasionally  attacks  of  retention  occur.  Diverticulum  may  form  a  distinct 
tumor  which  may  be  palpable  either  over  the  pubis  or  in  the  sacral  concavity 
by  rectal  examination.  Catheterization  will  draw  off  the  urine  in  the  bladder, 
and  by  pressure  a  further  quantity  can  be  evacuated,  often  exhibiting  pus  in 
considerable  quantity.  With  the  evacuation  of  this  added  quantity  the  tumor 
will  disappear.  Cystoscopic  examination  will  show  the  opening  into  the  diver- 
ticulum. At  times  lamps  can  be  passed  through  the  opening,  or  at  least  catheters 
can  be  introduced.  The  X-ray  with  collargol  distention  gives  the  clearest 
picture  of  the  condition.  Diverticular  openings  usually  lie  near  the  ureteral 
orifices. 

Complicating  cystitis  exhibits  a  distinct  predilection  for  middle-aged  males. 
In  the  absence  of  cystitis  diverticula  are  mainly  symptomless. 

The  treatment  of  inflamed  diverticula  may  be  palliative,  by  irrigations  and 
instillations  through  ureteral  catheters,  or  radical,  by  extirpation.  The  operation 
is  best  performed  through  a  long  median  suprapubic  incision,  following  the 
technique  of  Squier  for  cystectomy  (see  p.  557). 

Patent  Urachus. — Occasionally,  as  a  congenital  defect,  the  communication 
between  the  bladder  and  the  allantois  is  not  entirely  obliterated,  and  after 
birth  urine  escapes  through  the  umbilicus.  This  condition  is  usually  due  to  the 
back  pressure  incident  to  urethral  obstruction. 

Treatment  consists  in  first  rendering  the  urethra  patulous.  This  in  itself 
is  often  sufficient  to  produce  a  cure.  If  the  fistula  still  persists,  an  occlu».iing 
dressing,  the  application  of  the  actual  cautery,  or  excision  of  the  sinus  is  indi- 
cated. Urinary  concretions  may  form  in  these  fistulae.  Occasionally  suppurat- 
ing urachal  pouches  which  do  not  communicate  with  the  bladder  discharge  pus 
through  the  umbilicus,  or,  if  the  umbilical  opening  becomes  occluded,  form 
prevesical  tumors  or  abscesses.  The  treatment  is  complete  excision  of  the  sup- 
purating sac. 

Hypertrophy  of  the  Bladder. — This  term  implies  an  overgrowth  of  the 
vesical  muscles.  Sometimes  if  is  associated  with  marked  thickening  of  the 
mucosa.  It  is  always  caused  by  increased  functional  activity  incident  to 
mechanical  obstruction,  to  the  escape  of  urine  from  the  bladder,  or  to  abnormally 
frequent  micturition. 

In  cases  of  obstruction,  particularly  if  it  is  at  the  vesical  neck,  there  is 
usually  coincident  with  hypertrophy  a  dilatation,  often  a  partial  sacculation, 
of  the  bladder,  the  weaker  portions  of  the  walls  between  the  thickened  muscular 
fasciculi  yielding;  this  condition  is  known  as  eccentric,  trabecular  h\'pertrophy 
(Fig.  241).  In  vigorous  young  men,  and  this  particularly  represents  the  type 
suffering  from  chronic  stricture,  muscular  hypertrophy  may  be  universal,  the 
resulting  increased  expulsive  force  of  the  bladder  preventing  retention  and 
secondary  dilatation.     In  older  men,  with   enlarged  prostates,   the  typically 


474 


GENITO-URINARY  SURGERY 


dilated,  thickened,  trabeculated,  and  possibly  sacculated  bladder  develops. 
Hypertrophy  dependent  upon  frequent  urination  without  obstruction,  as  in 
some  cases  of  chronic  posterior  urethritis,  is  always  concentric  and  lessens  the 
size  of  the  vesical  cavity  (Fig.  242).  Cystitis  is  usually  associated  with 
hypertrophy,  adding  to  the  thickness  of  the  bladder-walls. 


Fig.  241. — Excentric  trabecular  hypertrophy  of  the  bladder.  The 
vesical  hypertrophy  in  this  case  is  incident  to  urethral  stricture.  The  trabec- 
ulae  and  diverticula  are  particularly  well  marked.  Observe  also  the  presence 
of  hydro-ureters  and  hydronephroses.  (From  the  Mutter  Museum,  College 
of  Physicians  of  Philadelphia.) 

The  ultimate  prognosis  of  hypertrophy  is  bad,  since  fibroid  or  fatty  degen- 
eration is  liable  to  occur,  with  consequent  diminution  or  entire  loss  of  con- 
tractile power. 

Diagnosis. — This,  when  the  hypertrophy  is  associated  with  trabeculation 


SURGERY  OF  THE  BLADDER 


475 


and  dilatation,  is  made  by  the  cystoscope.  When  there  is  concentric  hyper- 
trophy without  dilatation,  the  lessened  capacity  of  the  bladder  and  the  detec- 
tion of  its  greatly  thickened  walls  by  bimanual  rectal  and  suprapubic  palpation, 
together  with  a  preceding  history  of  either  frequent  or  difficult  micturition, 
point  to  the  true  nature  of  the  affection. 

Treatment. — The  direct  treatment  of  the  hypertrophy  is  unavailing.  Relief 
of  obstruction  or  of  the  necessity  for  frequent  micturition  will  prove  curative 
if  this  is  accomplished  before  degenerative  changes  have  begun. 

Atrophy  of  the  bladder  may  be  caused  by  distention  or  by  degeneration 
consequent  on  nerve-lesion.  In  old  age  there  has  been  observed  a  fatty  degen- 
eration of  both  the  detrusor  and  sphincter  muscles.  As  a  result  of  muscular 
atrophy  the  bladder  loses  the  power  of  evacuating  its  contents  and  becomes  a 
thin,  sometimes  enormously  dilated  pouch.  If  the  sphincters,  including  the 
compressor  urethrse  muscle,  are  atrophied,  there  will  result  incontinence  of 
urine;    this  symptom  is  usually  associated  with  retention. 


Fig.  212. — Concentric  hypertrophy  of  the  bladder. 

Atony  of  the  Bladder. — Weakness  of  the  bladder  muscularis,  almost 
physiological  in  people  past  middle  life,  is  usually  due  to  overdistention,  which 
may  be  acute  and  temporary  as  from  lack  of  privacy  for  an  urgently  desired 
act  of  micturition,  sudden  urethral  obstruction,  or  post-traumatic  retention,  or 
may  be  chronic  and  persistent  as  from  gradually  developed  urethral  obstruc- 
tion or  habitual  deferring  of  the  act  of  micturition.  The  hypertrophied  blad- 
der inevitably  becomes  atonic,  as  does  the  viscus  which  is  subject  to  prolonged 
drainage.  The  atonic  bladder  may  form  a  thin,  enormous  pouch,  containing 
many  pints  of  fluid  (Fig.  243). 

Diagnosis. — This  is  based  on  the  history  of  an  adequate  cause,  since  except 
in  the  aged  and  in  those  subject  to  exhausting  fevers  atony  is  never  primary. 
The  stream  of  urine  lacks  in  propulsive  force  even  when  a  catheter  is  passed, 
unless  the  abdominal  muscles  are  brought  into  play.  There  is  always  some 
residuum  after  urination,  hence  frequency  of  urination  is  usually  noted. 


476 


GENITO-URINARY  SURGERY 


Treatment. — After  removal  of  the  cause  and  the  cure  of  the  commonly 
accompanying  cystitis,  the  atonic  condition  of  the  vesical  muscles  may  be  bene- 
fited by  pituitrin  hypodermically,  strychnine,  irrigations  with  hot  normal  salt 
solution,  and  the  use  of  the  slowly  interrupted  faradic  current,  one  electrode 
being  introduced  into  the  bladder,  which  should  contain  not  more  than  four 
ounces  of  fluid. 

Hernia  of  the  Bladder. — Under  this  term  is  included  protrusion  of  a  part 


Fig.  243. — Atony  of  the  bladder,  with  dilatation.     (From  a  specimen  in  the  Museum  of  the 
Philadelphia  Hospital.) 

of  the  bladder-wall  along  the  track  usually  taken  by  intestinal  hernia.  Inguinal 
cystocele  is  the  common  form,  though  there  are  instances  of  obturator,  crural, 
vaginal,  and  perineal  vesical  hernia. 

Inguinal  cystocele  may  appear  in  the  form  of  a  projection  of  the  bladder 
without  a  true  hernial  sac — that  is,  without  a  peritoneal  covering — the  mus- 
cular coat  of  this  viscus  lying  in  immediate  contact  with  the  transversalis  fascia 
and  adhering  to  it.  This  is  the  usual  form,  and  rarely  attains  large  dimen- 
sions. Exceptionally  there  is  partial  or  complete  sacculation  at  the  expense 
of  the  peritoneal  investment  of  the  bladder.     Still  more  rarely  the  herniated 


SURGERY  OF  THE  BLADDER  477 

bladder  forms  a  tumor  erxtirely  covered  by  its  own  peritoneum  and  invested 
in  an  additional  true  peritonea!  sac.  Either  the  summit  or  the  lateral  surface 
of  the  bladder  is  the  portion  found  prolapsed.  Even  the  most  pronounced  dis- 
placement is  not  sufficiently  extensive  to  displace  the  ureters. 

The  herniated  portion  of  the  bladder  usually  presents  thin  walls,  is  often 
surrounded  with  considerable  fat,  and  sometimes  appears  as  a  diverticulum 
with  an  extremely  small  opening  into  the  general  vesical  cavity,  the  capacity 
of  the  latter  not  being  particularly  diminished.  From  stagnation  of  the  urine 
in  these  diverticula  calculi  may  form. 

The  causes  of  hernia  of  the  bladder  are  overdistention  and  dilatation  of  this 
organ  and  a  patulous  condition  of  the  hernial  orifices.  When  the  bladder  is  the 
first  viscus  to  appear  in  the  hernial  region,  its  anterior  surface,  uncovered  by 
peritoneum,  descends,  possibly  dragged  down  by  a  preceding  lipomatous  forma- 
tion. After  this  follows  the  part  covered  by  peritoneum,  forming  an  artificial 
sac,  into  which  the  gut  may  subsequently  descend.  The  most  frequent  cause  of 
bladder  hernia  is  a  preceding  intestinal  hernia,  which,  as  it  progresses  and 
drags  on  the  peritoneum  in  the  formation  of  a  sac,  involves  the  bladder. 

Symptoms. — The  characteristic  symptom  of  hernia  of  the  bladder  is  the 
presence  of  a  fluctuating  tumor,  dull  on  percussion  and  varying  in  size  in 
accordance  with  the  amount  of  urine  contained  in  the  bladder.  This  tumor 
may  not  grow  smaller,  even  though  the  bladder  be  completely  emptied,  since 
it  may  communicate  by  a  small  orifice,  which  is  closed  when  the  patient  is  in 
the  erect  position.  On  lying  down,  however,  and  particularly  after  manipula- 
tion and  gentle  pressure  which  causes  a  desire  to  urinate,  the  somewhat  tense 
fluctuating  tumor  becomes  small  and  flaccid,  and  immediately  a  quantity  of 
urine  can  be  again  evacuated.  The  flaccid,  inconspicuous  swelling  becomes 
tense  and  full  when  injections  are  forced  into  the  bladder.  These  symptoms 
are  absolutely  diagnostic.  In  addition,  there  are  often  symptoms  of  bladder 
irritation,  such  as  frequent  and  difficult  urination,  retention,  or  evident  cystitis. 
Exceptionally,  when  the  herniated  portion  of  the  bladder  is  small,  it  offers  no 
symptoms  other  than  those  associated  with  an  irreducible  omental  hernia. 

Vesical  hernia  is  commonly  complicated  by  enterocele  or  epiplocele.  Usually 
this  displacement  is  not  suspected  till,  in  the  course  of  operation  for  intestinal 
hernia,  escape  of  urine  shows  that  the  bladder  has  been  opened.  When  there 
is  more  than  the  usual  amount  of  fat  projecting  from  the  inner  portion  of  the 
opening  through  which  a  direct  inguinal  hernia  comes,  the  presence  of  the  bladder 
should  be  suspected. 

Treatment  for  this  affection  should  be  operative.  A  truss  is  not  well  borne, 
and  reduction  is  impossible.  The  operation  consists  in  carefully  dissecting  the 
bladder  free  of  its  adhesions,  reducing  it  to  its  proper  position,  and  perma- 
nently closing  the  hernial  opening. 

WOUNDS,   CONTUSION,   AND    RUPTURE    OF   THE   BLADDER 

The  bladder  when  empty  is  so  deeply  placed,  so  well  protected  by  the  bones 
of  the- pelvis,  and,  moreover,  so  movable,  at  least  in  its  upper  part,  that  it 
usually  escapes  the  effects  of  even  severe  traumatism.  When  force  has  been 
applied  sufficient  to  fracture  the  pelvic  bones  or  to  cause  disjunction  at  the 


478  GENITO-URINARY  SURGERY 

pubic  symphysis,  even  the  empty  bladder  may  be  bruised,  punctured  or  lacer- 
ated. Horns,  weapons,  or  pointed  stakes  may  wound  this  viscus  when  driven 
into  the  perineum  or  rectum,  through  the  obturator  or  sciatic  foramen,  or  above 
the  pubis.  Bullets  may  reach  the  bladder  either  through  the  outlets  of  the 
pelvis  or  directly  through  its  bony  substance.  Rough  instrumentation  may 
cause  laceration  of  the  vesical  walls.  Finally,  when  the  bladder  is  full  or  over- 
distended,  force  applied  from  without,  even  though  insufficient  to  cause  dis- 
juncture  of  the  pelvic  bones  or  superficial  bruising,  may  occasion  either  con- 
tusion or  rupture  of  the  bladder. 

Wounds  of  the  Bladder. — The  term  wound  implies  a  solution  of  the  con- 
tinuity of  the  soft  parts  extending  from  the  skin  surface  down  to  the  bladder- 
lesion.  Rupture  and  contusions  will  be  separately  considered.  Nearly  all 
wounds  of  the  bladder  can  be  classed  as  contused  or  lacerated,  including  under 
these  headings  gunshot  wounds. 

Incised  wounds  are  usually  inflicted  by  the  surgeon,  either  intentionally,  as 
in  cystotomy,  or  accidentally,  as  in  extirpation  of  pelvic  tumors.  In  the  latter 
case  prompt  closure  of  the  wound  by  suture  is  nearly  always  followed  by  imme- 
diate union,  the  danger  incident  to  this  accident  lying  in  the  risk  that  it  may 
be  overlooked.  When  the  wound  does  not  entirely  penetrate  the  visceral  wall, 
involving,  for  instance,  the  serous  and  muscular  coats  only,  the  mucous  coat 
remaining  intact  prevents  extravasation,  and  cicatrization  is  unhindered. 

Contused  and  lacerated  wounds,  the  common  variety,  are  usually  inflicted 
by  way  of  the  perineum  or  the  rectum,  as  the  result  of  a  fall  upon  a  stake  or 
a  paling,  or  are  due  to  wounding  by  firearms.  They  are  also  caused  by  inad- 
vertence in  surgical  manipulations.  Thus,  Neumann  in  extracting  a  stone 
adherent  to  the  vesical  wall  in  a  boy,  aged  nine,  tore  an  opening  through  both 
bladder  and  rectum.  In  accordance  with  the  portion  of  the  bladder  involved 
the  wound  is  termed  intraperitoneal  or  extraperitoneal.  From  the  standpoint 
of  prognosis  this  classification  is  important. 

Symptoms. — The  symptoms  of  wound  of  the  bladder  are— 1,  escape  of  urine 
through  the  wound;  2,  frequent  straining  effort  at  urination,  with  the  passage 
of  blood  or  bloody  urine;  3,  the  detection  of  an  opening  in  the  bladder  by 
means  of  a  probe  passed  through  the  wound,  or  of  a  sound  passed  through  the 
urethra,  aided  by  digital  examination  per  rectum,  or  by  a  combination  of  these 
methods.  Cystoscopic  examination  may  be  needful  before  formulating  a 
diagnosis. 

Hsematuria  may  be  the  only  symptom.  Escape  of  urine  through  the  wound 
can  take  place  only  when  the  tract  of  the  latter  is  of  some  size  and  is  fairly 
direct.  In  the  case  of  a  small  wound,  such  as  would  be  made  by  a  twenty-two- 
calibre  pistol-ball,  the  tract  remains  direct  only  so  long  as  the  bladder  main- 
tains the  same  degree  of  distention  as  at  the  moment  of  wounding.  As  the 
bladder  contracts  the  opening  through  its  walls  no  longer  lies  in  the  same  line 
as  the  wound  of  the  parietes.  Moreover,  contraction  of  the  muscular  layers 
makes  the  opening  through  their  substance  smaller,  and  the  mucous  membrane 
has  a  tendency  to  prolapse,  and  thus  occlude  the  wound  more  or  less  com- 
pletely. It  is  only  when  the  wound  is  large  and  direct  that  this  pathognomonic 
sign  of  bladder-rupture  will  be  found. 


SURGERY  OF  THE  BLADDER  479 

Though  tenesmus  and  the  frequent  voiding  of  a  small  quanuty  of  blood  or 
bloody  urine  are  noted  as  a  rule,  these  symptoms  are  not  invariably  excited. 
There  may  be  absolute  inability  to  pass  anything  from  the  bladder  by  the 
urethra.  Introduction  of  a  probe  into  the  bladder  through  the  wound  is  most 
difficult  where  this  viscus  has  changed  the  relation  of  its  wounded  wall  to  the 
parietes,  though  when  this  manoeuvre  is  successful,  and  when  the  probe  can  be 
made  to  strike  a  metal  catheter  carried  through  the  urethra  into  the  bladder, 
the  diagnosis  is,  of  course,  certain. 

Complications  of  Wounds  of  the  Bladder. — Immediately  following  a 
wound  of  the  bladder  hemorrhage  may  prove  a  serious  complication ;  this,  when 
so  violent  as  to  threaten  immediate  death,  comes  from  the  large  vascular  trunks 
in  the  pelvis,  and  not  from  the  bladder-wall. 

In  a  few  hours  or  days  usually,  but  sometimes  in  cases  of  gunshot  wounds 
not  until  after  one  or  two  weeks,  septic  peritonitis  may  develop  from  intra- 
peritoneal wounds,  or  septic  cellulitis  from  extraperitoneal  wounds. 

The  remote  complications  are  fistulse,  which  may  pass  from  the  bladder  to 
the  vagina,  to  the  rectum,  or  to  the  external  skin  surface,  and  concretions  which 
may  be  formed  around  foreign  bodies,  such  as  shot,  bullets,  fragments  of  the 
garments,  or  splinters  of  bone. 

Diagnosis. — When  the  typical  symptoms  are  present  the  diagnosis  is  easily 
made.  When  these  symptoms  are  mainly  wanting  and  the  presence  of  bloody 
urine  and  a  wound  of  entrance  passing  in  the  direction  of  the  bladder  are  the 
only  signs  suggestive  of  the  lesion,  examination  of  the  vesical  walls  by  means 
of  a  sound  passed  through  the  urethra,  aided  by  digital  exploration  through  the 
rectum,  is  indicated.  If  this  is  not  conclusive  in  its  results,  the  injection  and 
immediate  withdrawal  of  a  measured  quantity  of  dilute  antiseptic  solution  may 
prove  serviceable.  (See  Rupture  of  the  Bladder.)  If  this  does  not  clear  the 
diagnosis,  the  cystoscope  should  be  used,  the  bladder  being  first  washed  clear 
of  blood  by  irrigation  with  a  hot  antiseptic  solution.  If  there  is  too  much  blood 
in  the  bladder  to  allow  of  the  use  of  the  cystoscope,  suprapubic  or  perineal  cys- 
totomy should  be  performed  for  the  purpose  of  establishing  the  diagnosis,  the 
choice  of  operation  depending  on  the  position  of  the  external  wound. 

Prognosis. — This  depends  upon  whether  the  wound  is  extraperitoneal  or 
intraperitoneal.  The  intraperitoneal  wounds  are  generally  fatal  from  septic 
peritonitis,  though  recovery  from  extravasated  urine  becoming  encysted  and 
absorbed,  or  from  closure  of  the  bladder-wound  by  adherence  of  bowel  or  omen- 
tum to  its  peritoneal  aspect,  is  possible. 

The  prognosis  of  extraperitoneal  wounds  is  much  more  favorable;  in  the 
absence  of  lesions  of  other  organs  the  large  majority  will  recover.  Large,  clean, 
direct  wounds,  and  wounds  inflicted  by  vulnerating  bodies  entering  through  the 
rectum  or  the  vagina,  usually  drain  well.  The  outlook  for  gunshot  wounds  is 
favorable  in  proportion  to  the  freedom  with  which  urine  escapes  to  the  surface: 
hence  wounds  of  both  entrance  and  exit  are  less  serious  than  wounds  of  entrance 
alone.  When  from  lack  of  thorough  drainage  extraperitoneal  urinary  extrava- 
sation and  cellulitis  occur,  the  symptoms  become  pronounced  at  about  the  end 
of  the  first  week. 

Treatment. — Since  extravasation  of  urine  and  subsequent  septic  inflamma- 


480  GENITO-URINARY  SURGERY 

tion  are  the  main  dangers  incident  to  wound  of  the  bladder,  the  most  impor- 
tant indication  in  the  treatment  of  these  wounds  is  so  to  provide  for  drainage  of 
the  bladder  that  there  can  be  no  accumulation  of  urine,  and  hence  no  condition 
favoring  escape  of  this  fluid  into  the  peritoneal  cavity  or  the  cellular  tissues. 

When  the  wound  is  intraperitoneal,  it  is  safe  to  assume  that  blood  and 
urine  have  already  entered  the  peritoneal  cavity.  Hence  immediate  laparotomy 
is  advisable,  followed  by  closure  of  the  bladder-opening  by  suture,  closure  of 
the  abdominal  wound,  if  there  has  been  no  preceding  bladder  infection  and  no 
evidence  of  peritoneal  infection  and  permanent  catheterization;  in  case  the 
catheter  is  repeatedly  blocked  by  clots,  either  suprapubic  or  perineal  drainage 
should  be  resorted  to  at  once.  The  urine  should  be  rendered  antiseptic  by  the 
administration  of  salol  or  urotropin,  and  all  manipulations  must  be  conducted 
Avith  the  utmost  cleanliness,  since  the  wounded  bladder  is  strongly  predisposed 
to  cystitis.  When  the  wound  is  extraperitoneal,  suprapubic  or  perineal  drain- 
age is  indicated  in  accordance  with  the  position  and  direction  of  the  woimd. 
Suture  of  the  bladder  is  in  these  cases  rarely  practicable. 

Hemorrhage  is  treated  in  accordance  with  general  indications — i.  e.,  when 
it  is  moderate,  injections  of  hot  lotions  (four  per  cent,  solution  of  antipyrin) 
may  be  employed,  together  with  the  hypodermic  administration  of  blood  serum. 
When  it  is  severe  and  persistent,  it  may  require  packing,  the  application  of 
forceps,  or  incision,  exposure  of  the  bleeding  points,  and  ligation,  these  pro- 
cedures being  supplemented  by  direct  transfusion. 

Peritonitis  requires  immediate  laparotomy,  cleansing,  and  thorough  drainage. 

Pelvic  cellulitis  is  treated  by  free  incisions  carried  deep  into  the  perineum, 
the  ischiorectal  fossa,  over  the  pubis  into  the  space  of  Retzius,  or  wherever 
else  there  is  a  uro-purulent  infiltration. 

Contusion  of  the  Bladder. — Contusion  of  a  healthy  bladder  without  rup- 
ture of  its  walls,  though  proved  to  be  possible  by  a  few  reported  cases,  is  prob- 
ably a  rare  form  of  injury.  Theoretically  it  may  be  produced  by  the  causes 
which  occasion  rupture  of  this  viscus,  particularly  by  force  applied  to  the  ante- 
rior abdominal  wall  when  the  bladder  is  overdistended.  It  is  easy  to  imagine 
that  if  this  force  is  concentrated  it  may  cause  rupture  of  some  of  the  blood- 
vessels lying  in  or  beneath  the  mucous  membrane,  and  thus  may  cause  bleeding 
into  the  bladder. 

The  symptoms  of  this  injury  are  commonly  partial  or  complete  retention, 
tenesmus,  pain,  tenderness,  and  the  passage  of  blood-stained  urine  and  of  clots. 
Shock  should  be  moderate  or  altogether  wanting.  It  is  possible,  particularly 
in  a  bladder  which  has  been  the  seat  of  disease,  that  bleeding  may  be  per- 
sistent and  severe. 

The  diagnosis  is  of  importance,  since  this  injury  must  be  distinguished  from 
rupture.  Examination  with  the  cystoscope  after  bleeding  has  stopped  may  aid 
in  excluding  rupture.  Most  reliance  can  be  placed  on  injection  of  the  bladder 
with,  a  measured  quantity  of  antiseptic  solution.  If  such  a  solution  is  forced 
in  under  moderate  pressure,  is  retained  for  two  or  three  minutes,  and  on  being 
withdrawn  by  a  catheter  is  found  to  have  lost  nothing  in  volume,  it  is  fair 
to  assume  that  there  is  no  breach  in  the  continuity  of  the  vesical  wall. 

Treatment. — The  treatment  of  contusion  depends  entirely  on  the  severity 


SURGERY  OF  THE  BLADDER  481 

of  the  symptoms.  When  bleeding  is  sHght  and  there  is  httle  or  no  retention, 
rest,  the  mouth  administration  of  urinary  antiseptics,  and  the  control  of  tenes- 
mus and  pain  by  hot  baths,  hot  abdominal  compresses,  and  opium  and  bella- 
donna suppositories  will  fulfil  the  therapeutic  indications.  Even  when  there  is 
some  obstruction  by  blood-clots  to  the  free  passage  of  urine,  it  is  well  to  abstain 
from  interference,  provided  dirty  instruments  have  not  been  passed  into  the 
bladder  previously  and  the  urine  is  sterile.  Should  retention  become  well 
marked,  a  sterile,  full-sized  catheter  should  be  passed  immediately,  under  the 
antiseptic  cautions  described  when  treating  of  retention,  and  the  clots  sucked 
out  by  a  syringe,  or,  if  this  fails,  by  means  of  the  large  evacuating  catheter  and 
aspirator  of  a  litholapaxy  instrument.  If  there  is  persistent  bleeding,  continuous 
catheterization  is  indicated.  Should  the  hemorrhage  be  profuse,  suprapubic 
cystotomy  should  be  performed;  the  bleeding  points  can  then  be  subjected  to 
direct  treatment.  If  there  is  cystitis,  clots  should  be  evacuated,  even  though 
there  is  no  retention,  and  the  bladder  should  be  irrigated  twice  daily  with  a  mild 
antiseptic  solution  (silver  nitrate  1  to  1000,  boric  acid  four  per  cent.,  or 
Thiersch's  solution). 

Rupture  of  the  Bladder. — This  injury  may  be  either  intraperitoneal  or 
extraperitoneal.  It  may  be  traumatic  or  pathological.  So-called  idiopathic 
cases  are  always  secondary  to  some  obstructive  or  degenerative  factor.  It 
usually  occurs  at  about  the  prime  of  life. 

The  causes  of  rupture  of  the  bladder  are  predisposing  and  exciting. 

Of  the  predisposing  causes  the  one  of  greatest  importance  is  the  condition 
of  distention.  Indeed,  it  is  difficult  to  imagine  how  the  empty  viscus  can  be 
ruptured  unless  there  are  extensive  concomitant  injuries. 

Alcoholism  is  a  predisposing  factor,  but  mainly  because  it  tends  to  encourage 
a  condition  of  overdistention  of  the  bladder,  from  the  fact  that  it  stimulates  the 
kidneys,  and  so  obtunds  sensibility  that  the  desire  to  micturate  is  not  noticed, 
even  when  the  bladder  is  full. 

Fixation  of  the  bladder  by  pelvic  cellulitis,  degeneration  of  its  walls  from 
chronic  cystitis  or  atheroma,  and  disturbed  innervation,  may  also  be  counted  as 
predisposing  factors. 

The  exciting  causes  are  fracture  of  the  pelvis,  separation  of  the  pubic  sym- 
physis, violence  applied  either  directly  or  indirectly,  and  muscular  strain.  Thus, 
kicks  in  the  stomach,  falls  upon  the  ischium,  and  the  straining  incident  to  par- 
turition, defecation,  urination,  or  lifting,  have  caused  this  injury. 

Vesical  tension  from  acute  retention  of  urine,  or  from  injections  practised 
for  the  cure  of  cystitis  or  in  the  preparation  for  stone  operations,  may  cause 
rupture  of  the  bladder  without  the  intervention  of  strains  of  traumatism. 

Thus,  Dittel  performed  suprapubic  cystotomy  for  the  removal  of  a  stone 
in  a  child  aged  three.  The  bladder  was  injected  with  not  more  than  three 
ounces,  and  the  colpeurynter  contained  not  over  four  ounces.  The  patient  per- 
ished the  next  day  in  collapse,  with  symptoms  of  pericystitis.  In  the  posterior 
wall  of  the  bladder  there  was  found  a  tear  two-fifths  of  an  inch  in  length,  run- 
ning into  a  diverticulum.  This  caused  infiltration  of  the  pericystic  cellulai 
tissue. 

Pathological  rupture — that  in  which  the  bladder-walls  give  way  from  over- 
31 


482  GENITO-URINARY  SURGERY 

distenticn,  without  the  intervention  of  force — is  usually  due  to  an  enlarged 
prostate,  since,  in  the  case  of  stricture,  the  urethra  usually  ulcerates  posterior  ' 
to  the  seat  of  narrowing,  and  tension  is  relieved  by  extravasation  of  urine  into 
the  periurethral  cellular  tissues.  It  is  probable  that  the  majority  of  cases  of 
rupture  attributable  to  muscular  strain  will  exhibit  pathological  changes  inci- 
dent to  urethral  obstruction,  the  great  thickening  of  the  bladder-walls  occa- 
sioned by  such  obstruction  proving  no  safeguard  against  this  accident.  Cystitis 
in  these  cases  is  usually  complicated  either  by  ulceration  or  by  sacculation,  thus 
leaving  a  weak  portion,  which  may  rupture  from  slight  causes. 

The  seat  of  rupture  may  be  either  intraperitoneal  or  extraperitoneal.  Fen- 
wick  states  that  it  is  intraperitoneal  in  eighty-eight  per  cent,  of  cases.  Ulmann 
estimates  the  proportion  at  eighty-five  per  cent.  The  greater  frequency  of 
intraperitoneal  rupture  is  partly  due  to  the  fact  that  the  area  covered  by  the 
peritoneum  is  larger  and  is  less  reinforced  by  the  pressure  of  closely  attached 
surrounding  tissues.  Moreover,  the  peritoneum  is  less  elastic  and  distensible 
than  the  other  coats,  and,  splitting  suddenly,  tears  the  muscular  and  mucous 
coats  with  it.  Direct  force  applied  to  the  hypogastric  region  usually  causes  a 
tear  of  the  upper  posterior  bladder-wall.  Ruptures  due  to  fracture  of  the  pelvis 
and  spontaneous  ruptures  are  apt  to  be  extraperitoneal.  The  rupture  is  com- 
monly single,  is  vertical  or  oblique  in  direction,  and  when  intraperitoneal  the 
peritoneal  aspect  is  most  extensively  torn. 

Symptoms. — The  symptoms  of  rupture  of  the  bladder  are  a  sense  of  some- 
thing giving  way  within  the  abdomen,  hypogastric  pain,  often  agonizing,  con- 
stant desire  to  urinate,  passage  of  a  few  drops  of  blood,  or  of  blood-stained 
urine,  or  failure  to  pass  anything,  and  shock. 

Following  these  symptoms,  under  appropriate  treatment  reaction  usually 
takes  place,  and  there  is  a  period,  varying  from  hours  to  days,  during  which  the 
patient  suffers  from  pain  and  tenderness  in  the  hypogastric  region,  'tenesmus, 
and  a  constant  desire  to  micturate,  and  passes  little  or  no  urine. 

Exploration  of  the  hypogastric  region  demonstrates  percussion  dulness  and 
a  sense  of  resistance  closely  simulating  that  of  a  distended  bladder,  while  rectal 
examination  may  show  effusion  into  Douglas's  cul-de-sac  or  the  cellular  tissues 
lying  at  the  base  of  the  bladder.  There  then  follows,  in  accordance  with  the 
location  of  the  rupture,  either  septic  peritonitis,  usually  terminating  fatally  in 
five  days,  or  cellulitis,  which  progresses  more  slowly,  and  is  attended  with  the 
symptoms  of  septicaemia,  sometimes  running  a  course  of  several  weeks. 

Diagnosis. — The  diagnosis  of  rupture  of  the  bladder  is  founded  upon  the 
history  of  the  case,  the  symptoms  already  detailed,  notably  shock,  tenesmus, 
urgent  desire  to  micturate,  which  the  patient  cannot  satisfy,  or  frequent  urina- 
tion and  the  passage  o:'  blood,  and  upon  the  results  of  direct  examination.  All 
the  subjective  symptoms  may  be  excited  by  contusion  of  the  abdomen;  if  there 
is  also  contusion  of  the  bladder  the  urine  will  contain  blood.  The  bladder  may 
be  ruptured  without  exciting  a  single  characteristic  symptom.  Coates  reports 
two  cases  of  rupture  of  the  posterior  wall  in  which  the  lesion  was  not  suspected 
during  life,  no  signs  of  acute  peritonitis  having  developed.  The  peritoneal 
cavity  was  flooded  with  sterile  urine;  death  was  attributed  to  absorption  of  the 
urine  by  the  peritoneum,  with  a  consequent  toxic  effect  upon  the  blood.     In 


SURGERY  OF  THE  BLADDER  483 

two  of  thirty-five  cases  collected  by  Nobe,  the  urine  contained  no  blood.  In 
both  cases  the  rupture  occurred  at  the  vertex,  the  least  vascular  part  of  the 
bladder. 

The  simplest  method  of  exploration  consists  in  the  passage  of  a  thoroughly 
sterilized  silver  catheter  through  the  urethra,  first  flushing  it  thoroughly  with 
a  1  to  4000  protargol  solution.  If  this  draws  off  bloody  urine  and  clots,  the 
probability  of  rupture  is  strong.  If  on  manipulation  of  the  shaft  so  that  the  tip 
is  made  to  traverse  the  inner  surface  of  the  bladder  this  tip,  repeatedly  catches  at 
one  point,  and  apparently  can  be  passed  through  the  bladder-wall,  so  that  it  can 
be  felt  immediately  below  the  skin  or  mucous  membrane  surface  by  palpation 
in  the  hypogastric  region  or  through  the  rectum,  there  can  no  longer  be  doubt 
about  the  existence  of  a  rupture. 

Better  than  this  means  of  exploration  is  the  irrigating  cystoscope  if  it  be 
available. 

The  injection  of  an  antiseptic  solution  is  by  no  means  an  infallible  test, 
since  even  an  extensive  rupture  may  so  quickly  close  by  inflammatory  adhe- 
sion that  a  solution  injected  with  gentle  pressure  fails  to  break  this  down,  and 
the  total  quantity  injected  is  at  once  returned. 

Weir  states  that  this  injection  method  (Cabot's)  is  made  more  reliable  by 
several  repetitions,  enough  fluid  being  driven  in  each  time  markedly  to  distend 
the  bladder.  The  method  is  rendered  still  more  serviceable  by  preceding  the 
injection  by  a  careful  digital  examination  of  the  rectum,  followed  by  the  inser- 
tion and  distention  of  the  Barnes  bag.  The  bladder  is  then  injected  with  a 
known  volume  of  fluid.  If  there  results  lapid  increase  in  pelvic  tumor  and 
dulness,  as  detected  by  suprapubic  examination,  this  must  be  due  either  to  the 
distended  bladder  or  to  extravasated  fluid.  In  the  latter  event  failure  to  recover 
by  catheterization  all  the  fluid  injected  will  show  the  presence  of  an  extra- 
peritoneal rupture.  In  case  there  is  developed  no  suprapubic  dulness,  but  all 
the  fluid  is  not  recovered,  there  must  be  either  an  intraperitoneal  or  a  sub- 
peritoneal postero-inferior  rupture.  In  the  latter  case  withdrawal  of  the  Barnes 
bag  and  a  second  digital  examination  of  the  rectum  will  show  the  increase  of 
extravasation.  The  injection  of  air  is  not  more,  reliable  as  a  means  of  diagnosis 
than  is  that  of  water.  When  facilities  are  offered  for  this,  collargol  injections 
and  skiagraphy  should  give,  reliable  findings. 

In  case  of  doubt  there  should  be  no  hesitation  in  performing  either  a  supra- 
pubic or  a  perineal  cystotomy  and  thoroughly  exploring  the  bladder  by  the 
finger  and  by  sight.  Always,  when  instruments  are  used  for  diagnostic  pur- 
■  poses,  the  principles  of  surgical  cleanliness  must  be  minutely  observed,  and  if 
a  rupture  is  found,  operation  should  be  performed  at  once. 

Prognosis. — Rupture  of  the  bladder  results  fatally  in  a  large  proportion 
of  cases,  and  the  prognosis  is  particularly  grave  when  the  rent,  is  complicated 
by  fracture  of  the  pelvis  and  when  it  is  intraperitoneal,  death  resulting  in  the 
great  majority  of  these  cases  in  the  first  five  days.  Spontaneous  recovery, 
though  possible,  is  so  rare  as  to  constitute  a  surgical  curiosity.  The  extraper- 
itoneal tears  are  somewhat  less  fatal,  but  in  the  absence  of  proper  surgical 
intervention  the  majority  of  these  perish.  The  prognosis  is  undoubtedly  better 
to-day,  when  antiseptics  are  generally  employed  in  the  treatment  of  bladder- 


484  GENITO-URINARY  SURGERY 

lesions,  than  in  the  former  septic  period.  The  urine  when  first  extravasated 
from  a  healthy  bladder  is  a  sterile  fluid  and  does  not  cause  inflammation. 
Hence,  if  not  infected  by  the  use  of  dirty  instruments,  it  undergoes  changes 

slowly. 

The  conditions  for  germ-growth  are,  however,  so  favorable  that  the  slight- 
est infection  is  followed  by  rapid  and  extensive  suppuration.  The  mortality, 
if  that  from  shock  incident  to  associated  injuries  be  excepted,  is  inversely  pro- 
portional to  the  timeliness  of  surgical  intervention. 

Causes  of  death  are  most  frequently  peritonitis  (seventeen  of  twenty-six 
cases),  shock,  and  hemorrhage. 

Schlanger  notes  ten  recoveries  out  of  twenty-two  operations  for  intra- 
peritoneal rupture.  Seven  out  of  ten  were  cured  when  the  rupture  was 
extraperitoneal. 

Treatment. — If  the  wound  is  intraperitoneal,  an  immediate  laparotomy, 
siphoning  of  the  extravasated  blood  and  urine  from  the  peritoneal  cavity,  and 
closure  of  the  bladder  by  suture  are  indicated.  It  is  important  that  this  opera- 
tion should  be  performed  immediately — that  is,  before  the  beginning  of  per- 
itonitis. When  exploration  fails  to  show  whether  the  rent  is  intraperitoneal  or 
extraperitoneal,  suprapubic  cystotomy  should  be  performed  and  a  diagnosis  thus 
made;  if  further  room  is  required,  the  midline  incision  may  be  carried  upward 
or  the  sheaths  of  the  recti  muscles  may  be  split  transversely  and  the  muscles 
widely  retracted. 

The  sutures  by  which  intraperitoneal  bladder-wounds  are  closed  are  placed 
about  six  to  an  inch;  the  first  rov/,  preferably  of  fine  sterfle  catgut,  closes 
the  rent,  each  stitch  including  all  but  the  mucous  coat  of  the  bladder;  this 
line  of  union  is  then  turned  in  by  a  second  row,  the  suture  being  of  silk  and 
made  continuous.  The  peritoneal  surfaces  are  then  brought  in  apposition,  and 
inflammatory  agglutination  takes  place  in  less  than  twenty- four  hours.  When 
the  sutures  have  been  properly  applied  in  healthy  non-infected  tissue  there  is  no 
tendency  to  the  reopening  of  the  wound.  To  make  sure  that  the  wound  has  been 
thoroughly  closed,  the  bladder  should  be  moderately  distended  with  mild  anti- 
septic solution;  if  apposition  is  perfect  there  will  be  no  leakage.  When  septic  peri- 
tonitis has  already  developed,  tube  drainage  is  indicated.  In  large,  irregular, 
contused  or  lacerated  wounds  of  a  diseased  bladder  the  line  of  suture  cannot 
be  trusted.  The  wound  should  be  rapidly  closed  by  a  continuous  catgut  suture, 
reinforced  by  the  omentum  held  in  place  by  a  few  stitches. 

When  suprapubic  cystotomy  has  been  performed  for  exploratory  purposes  and 
the  rent  is  found  to  be  extraperitoneal,  it  should  be  thoroughly  cleansed  and 
closed  by  interrupted  suture.  The  results,  so  far  as  the  closure  of  the  wound 
is  concerned,  are  not  so  satisfactory  as  those  obtained  by  the  suture  of  intra- 
peritoneal openings.  Hence  a  drainage-tube  or  a  rubber-wrapped  gauze  wick, 
or  both,  should  lead  to  the  seat  of  injury,  thus  providing  for  the  free  escape  of 
urine  in  case  the  sutures  should  give  way. 

The  after-treatment  of  operation  for  bladder  rupture  consists  in  the  employ- 
ment of  continuous  catheterization  for  them  three  to  eight  days,  after  which 
the  patient  is  allowed  to  void  naturally  if  he  can,  otherwise  intermittent  cathe- 
terization is  practised  at  such  intervals  that  the  bladder  is  not  allowed  to  retain 


SURGERY  OF  THE  BLADDER  485 

more  than  ten  or  twelve  ounces  of  fluid.  The  method  of  using  continuous 
catheterization  is  the  same  as  that  described  under  the  treatment  of  retention 
from  prostatic  enlargement.  Extraperitoneal  ruptures  are  treated  by  permanent 
catheterization,  supplemented  by  antiseptic  irrigation  of  the  bladder  practised 
night  and  morning.  If  the  surgeon  distrusts  the  permanent  catheter,  as  he 
should  do  in  most  cases  with  extensive  and  complicated  wounds,  suprapubic 
drainage  or  the  insertion  of  a  tube  through  the  perineum  is  indicated. 

Pain,  particularly  that  referred  to  the  rectum  and  running  down  the  thighs, 
rigors  and  fever,  and  leucoGytosis  of  the  polymorphonuclear  type,  point  to 
extravasation  and  cellulitis,  and  indicate  either  a  suprapubic  or  a  perineal  cys- 
totomy. The  suprapubic  operation  is  preferable  unless  oedema,  tenderness,  and 
swelling,  which  may  be  evident  only  on  rectal  examination,  show  that  the  peri- 
neum is  the  seat  of  infiltration. 

FISTULA  OF  THE  BLADDER 

Vesical  fistula  is  an  anomalous  tract  leading  from  the  bladder  to  the  surface 
of  the  body  or  to  some  neighboring  viscus.  It  is  usually  due  to  the  failure  of 
a  surgical  or  an  accidental  wound  to  heal,  but  may  be  caused  by  erosion  from 
a  calculus  or  foreign  body,  burrowing  of  a  pericystic  abscess,  or  ulceration  of  a 
tuberculous  or  malignant  infiltration.  The  fistulous  tract  may  run  directly  or 
deviously  to  the  surface.  The  nomenclature  of  these  fistulas  is  indicative  of 
their  course:  thus,  they  are  termed  vesicoperineal,  vesicohypogastric,  vesico- 
gluteal,  etc.  Pathologically  these  ulcerating  channels  are  identical  with  urethral 
fistulae;  they  may  burrow  in  many  directions  and  open  by  several  orifices;  they 
often  develop  lateral  blind  diverticula,  and  they  become  densely  indurated. 

Symptoms. — Cystitis  is  a  symptom  common  to  all  forms  of  long-standing 
vesical  fistula.  Other  symptoms  vary  in  accordance  with  the  seat  of  the  extra- 
vesical  opening.  When  this  is  upon  the  skin  surface  there  is  an  obvious  escape 
of  urine. 

The  urine  may  dribble  almost  constantly  or  may  flow  intermittently.  When 
the  tract  is  narrow,  and  particularly  when  the  opening  in  the  tract  is  valvular, 
the  quantity  escaping  will  be  insignificant.  When  conditions  the  reverse  of  these 
obtain,  all  the  urine  may  pass  through  the  abnormal  opening.  The  skin  sur- 
rounding the  external  opening  of  the  fistula  shows  the  excoriation,  inflammation, 
and  infiltration  described  when  treating  of  urethral  fistulae.  During  the  act  of 
micturition,  or  when  intra-abdominal  pressure  is  increased  by  muscular  contrac- 
tion, as  in  the  act  of  lifting,  coughing,  or  defecation,  there  is  increased  flow  of 
urine  from  the  opening. 

When  the  fistula  opens  into  the  rectum,  if  the  channel  of  communication 
be  narrow,  there  may  be  no  symptoms  suggesting  this  communication  other 
than  a  urinous  discharge  occurring  often  with  the  passage  of  well-formed  stools. 
Usually,  however,  the  symptoms  of  this  fistula  are  sufficiently  characteristic. 
There  is  a  more  or  less  constant  escape  of  urine  from  the  rectum,  and  gas  and 
faeces  are  passed  by  the  urethra.  We  have  seen  a  case  due  to  cancer  of  the 
bowel,  in  which  nearly  all  the  faeces  were  passed  by  the  urethra  for  several 
months.  Fecal  masses,  by  blocking  the  urethra,  often  cause  retention  of 
urine.    Cystitis  under  such  circumstances  is  very  severe. 


4^  GEXITO-URINARY  SURGERY 

When  there  is  commumcation  between  the  bladder  and  the  small  intestines 
or  the  colon,  in  the  latter  case  usually  by  way  of  the  appendix  or  a  diverticulum, 
gas,  remnants  of  food,  and  traces  of  bile  will  be  passed  per  urethram,  but  the 
sohd  particles  found  in  the  urine  probably  will  not  exhibit  the  characteristics 
of  faeces.  There  will  be  no  urine  escaping  by  the  rectum,  or  none  which  can  be 
recognized  as  such,  since  it  is  thoroughly  mixed  with  the  rectal  contents. 

Diagnosis. — When  the  fistula  opens  externally  the  diagnosis  is  based  on — 
1,  escape  of  urine,  particularly  marked  during  abdominal  straining;  2,  escape 
of  colored  fluids  injected  into  the  bladder  or  methylene  blue  given  by  mouth; 
3,  urethral  examination,  a  sound  being  passed  into  the  bladder  and  a  fine  probe 
being  introduced  along  the  fistulous  tract;  4,  cystoscopic  examination;  5,  injec- 
tion of  hydrogen  peroxide  along  the  fistulous  tract,  bubbles  then  escaping  per 
urethram  at  the  next  act  of  micturition;  6,  palpation,  an  area  of  induration 
sometimes  being  perceptible  from  the  external  opening  directly  to  the  bladder- 
wall. 

WTien  the  fistula  opens  into  the  bowel  the  diagnosis  may  be  more  difficult. 
The  passage  of  air  at  the  end  of  micturition  is  in  itself  pathognomonic.  The 
detection  of  fragments  of  faeces  in  the  urine,  the  finding  of  urinary  salts  in  the 
liquid  passed  per  anum,  the  detection  of  an  opening  into  the  rectum  by  direct 
examination  through  a  speculum,  the  finding  of  a  bladder-opening  by  the 
cystoscope,  and  particularly  the  discovery  of  a  sufficient  cause  for  such  a  lesion, 
as,  for  example,  malignant  or  tuberculous  ulceration,  or  large  stone,  or  the 
history  of  appendicitis,  would  lead  to  a  correct  diagnosis.  Colored  solutions, 
such  as  methylene  blue,  if  injected  into  the  bladder,  or  if  administered  by 
mouth,  may  appear  in  the  stools,  thus  positively  establishing  the  existence  of  a 
vesicorectal  fistula. 

The  differential  diagnosis  between  vesical  and  urethral  fistula  is  based  upon 
the  fact  that  urine  escapes  from  the  latter  only  during  or  after  micturition, 
and  that  colored  fluids  injected  into  the  bladder  will  not  escape  through  the 
fistulous  opening  until  the  patient  urinates. 

Treatment. — Fistulae  due  to  tuberculous  and  malignant  infiltration  and  ulcer- 
ation are  incurable.  The  appropriate  treatment  is  that  directed  against  the 
cystitis.  Perineal  or  suprapubic  drainage  may  be  required.  Fistula  following 
operation,  if  small  and  comparatively  recent,  may  be  cured  by  continuous  cathe- 
terization, combined  with  antiseptic  washing  of  the  bladder  and  cauterization 
of  the  fistulous  tract,  preferably  with  the  galvanocautery.  This  failing,  the 
fistula  should  be  laid  open  to  the  bladder,  its  walls  dissected  out,  and  the  wound 
treated  as  it  would  be  after  the  operation  of  cystotomy. 

WTien  the  fistula  opens  in  the  gluteal  region  or  in  the  neighborhood  of  the 
hip-joint,  after  a  preliminary  effort  at  closure  by  catheterization  median  perineal 
lithotomy  should  be  performed,  and  the  bladder  should  be  drained  immediately 
through  this  opening. 

Small  rectovesical  fistulae  not  due  to  tuberculous  or  malignant  infiltration 
are  treated  on  the  same  general  principles.  At  first  catheterization  should  be 
tried,  combined  with  cauterization  of  the  fistulous  tract  through  the  rectum, 
after  which  a  permanent  catheter  should  be  worn  with  the  patient  in  ventral 
decubitus.    This  failing,  if  the  tract  is  extraperitoneal — that  is,  if  it  lies  below 


SURGERY  OF  THE  BLADDER  487 

the  rectovesical  peritoneal  fold — it  may  be  operated  on  as  described  in  the 
treatment  of  urethrorectal  fistula. 

When  the  fistulous  tract  is  intraperitoneal  and  when  it  persists  in  spite  of 
the  palliative  means  described,  a  formal  operation  is  indicated,  since  the  ultimate 
outlook  of  these  cases  if  untreated  is  bad,  death  resulting  from  ascending 
nephritis.  Immediately  preceding  the  operation  the  bladder  should  be  thor- 
oughly irrigated  with  dilute  antiseptics,  preferably  freshly  prepared  protargol, 
1  to  4000.  This  is  followed  by  irrigation  of  silver  nitrate  1  to  500.  The 
peritoneum  is  then  opened  just  above  the  pubis,  the  communication  between  the 
bowel  and  the  bladder  is  rendered  accessible,  and  the  intraperitoneal  operative 
area  is  packed  off  from  the  general  peritoneal  cavity  by  gauze  sponges;  the 
bowel  is  then  dissected  loose,  the  opening  into  it  is  closed  by  Lembert  sutures, 
the  first  continuous  and  including  all  its  coats  except  the  epithelial  layer  of  the 
mucous  membrane,  the  second  (Lembert)  including  only  the  peritoneal,  muscu- 
lar, and  submucous  investments. 

In  the  after-treatment  the  bladder  is  drained  for  from  three  to  five  days  by 
permanent  catheterization,  and  is  irrigated  twice  daily  with  lotions  of  protargol, 
1  to  4000,  boric  acid  four  per  cent.,  or  saHcylic  acid  one-tenth  per  cent. 


CHAPTER  XXII 

SURGERY  OF  THE  BLADDER— (Continued) 

INFECTIONS  OF  THE  BLADDER 

CYSTITIS 

Cystitis  is  an  inflammation  of  the  bladder  due  to  germ-infection. 

The  sudden  acute  congestion  due  to  retention,  chilling,  irritating  conditions 
of  the  urine,  or  foreign  body,  is  not  considered  as  a  true  inflammation,  since, 
unless  there  is  added  to  this  congestion  germ-infection,  the  condition  is  transi- 
tory, and  is  attended  by  no  lesions,  barring  vascular  engorgement.  Yet  while 
the  congestion  lasts  the  symptoms,  with  the  exception  of  pus  and  microor- 
ganisms in  the  urine,  are  identical  with  those  of  acute  cystitis. 

Classification. — Cystitis,  in  accordance  with  its  clinical  course,  may  be 
acute  or  chronic.    From  the  pathological  standpoint  the  disease  may  be — 

1.  Superficial  or  catarrhal. 

2.  Interstitial. 

3.  Pericystic. 

Further  subdivisions,  sufficiently  indicated  by  their  names,  are  pseudomem- 
branous cystitis  and  gangrenous  cystitis. 

Etiology. — The  causes  of  cystitis  are  predisposing  and  exciting.  The  pre- 
disposing causes  are  those  which  favor  congestion  and  retention,  the  latter  con- 
dition implying  the  former,  since  an  overfull  bladder  is  always  congested.  A 
normal  bladder  containing  normal  urine  which  is  evacuated  at  proper  intervals 
is  not  readily  infected.  Even  though  germs  be  carried  directly  into  its  cavity, 
by  dirty  instruments  for  instance,  the  resistance  of  the  healthy  tissues  is 
sufficient  to  prevent  penetration  and  multiplication  of  microorganisms. 

The  causes  of  vesical  congestion  are — 1.  Retention  of  urine.  The  vesical 
congestion  is  in  proportion  to  the  acufeness  of  the  retention:  hence  a  sudden 
distention  of  the  bladder  is  a  more  favoring  factor  in  the  development  of 
cystitis  than  is  a  gradual  accumulation  of  urine.  2.  Trauma.  This  may  be 
due  to  jar,  strain,  contusion  or  laceration,  rough  instrumentation,  or  bruising 
by  a  stone  or  other  foreign  body.  3.  Muscular  contractions  abnormally  frequent 
or  prolonged.  These  may  be  excited  reflexly  by  lesions,  irritations,  in  inflam- 
mations of  the  rectum,  sexual  organs,  kidneys,  or  urethra,  or  may  be  due  to 
hypersensitiveness  of  the  micturition  centre,  to  habit,  or  to  polyuria.  4.  Abnor- 
mal conditions  of  the  urine.  If  the  urine  is  essentially  changed  in  any  of  its 
characteristics,  it  will  eventually  act  as  an  irritant  to  the  vesical  mucosa.  If  it 
is  strongly  acid,  markedly  alkaline,  or  of  very  low  or  very  high  specific  gravity, 
it  occasions  congestion.  Thus,  the  gouty  and  rheumatic,  dyspeptics  suffering 
from  oxaluria,  phosphaturia,  or  other  urinary  changes,  diabetics,  cachectics  with 
haematuria,  persons  who  have  been  severely  burned,  and  those  who  have  ingested 
overdoses  of  such  drugs  as  cantharides,  turpentine,  the  balsams,  alcohol,  or 


SURGERY  OF  THE  BLADDER  489 

arsenic,  are  predisposed  to  cystitis  by  vesical  congestion.  5.  Tumors  and  calculi. 
It  should  be  borne  in  mind  that  tumors  and  calculi  do  not  in  themselves  cause 
cystitis,  but  merely  predispose  to  its  development  by  the  congestion  which  their 
presence  occasions,  and  by  the  admixture  of  blood  with  the  urine,  thus  rendering 
it  alkaline  and  peculiarly  rich  as  a  culture  fluid.  6.  Surface  chilling,  as  from 
getting  the  feet  wet  or  sitting  on  the  damp  ground,  may  cause  a  sudden  and  very 
marked  congestion  of  the  bladder,  though  never  a  true  cystitis.  7.  Prolonged 
sexual  excitement  or  excess  in  sexual  intercourse  is  a  potent  factor  in  the  pro- 
duction of  bladder  hyperaemia,  8.  Cardiac  weakness,  venous  obstruction,  and 
atheromatous  degeneration  of  the  vessels  are  factors  often  operative  in  the  aged, 
which  when  combined,  as  is  often  the  case,  with  an  enlarged  and  inflamed 
prostate,  and  hence  with  retention  of  urine,  make  the  development  of  cystitis 
nearly  certain.  9.  Lesions  of  the  central  nervous  system  by  destroying  vaso- 
motor control  and  favoring  retention  of  urine  strongly  favor  the  development 
of  cystitis. 

Congestion  of  the  bladder  is,  then,  the  condition  which  most  predisposes 
to  cystitis.  When  to  the  congestion  is  added  retention,  particularly  if  of  an 
alkaline  and  albumen-  or  blood-containing  urine,  the  most  favorable  conditions 
for  germ-infection  are  present.  It  is  clear  that  several  of  the  causes  of  acute 
congestion  may  be  operative  at  the  same  time:  thus,  during  acute  fever  there 
may  be  atonic  retention  of  urine  which  is  irritating  from  the  pyrexia;  or  after 
spinal  injury  there  may  be  vasomotor  dilatation,  combined  with  retention  from 
detrusor  paresis. 

The  exciting  cause  of  cystitis  is  local  infection.  This  infection  is  com- 
monly due  to  catheterization  or  urethritis.  The  microbes  may  also  enter  the 
bladder  from  the  kidneys,  by  the  agency  of  the  blood-  or  lymph-channels,  or 
they  may  pass  directly  from  the  rectum,  this  direct  passage  being  particularly 
liable  to  take  place  in  cases  of  constipation,  inflammation,  hemorrhoids,  or 
tumors  of  the  rectum,  as  shown  by  Wreder. 

Pericystic  suppuration  may  also  occasion  local  bladder-infection  by  destroy- 
ing the  bladder-wall  and  discharging  pus  into  its  cavity. 

Normal  urine  is  usually  sterile.  In  the  urine  of  cystitis  have  been  found  a 
great  number  of  organisms,  many  of  them  without  pyogenic  action.  Of  the 
inicroorganisms  which  occasion  cystitis  the  colon  bacillus  is  the  one  most  fre- 
quently found.  After  this  come  the  staphylococci  and  streptococci  of  ordinary 
pus  and  the  bacillus  proteus  vulgaris.  It  seems  clear  that  the  gonococcus  may 
invade  a  part  or  even  the  whole  of  the  trigonum,  but  there  is  evidence  that  the 
remaining  vesical  mucous  membrane  is  at  least  partially  immune  to  its  attack. 
Cases  of  true  bladder-inflammation  traceable  to  gonorrhoea  are  usually  due  to 
mixed  infection.  This  is  also  true  of  post-typhoid  cystitis,  though  cases  are 
reported  in  which  the  urine  contained  pure  typhoid  cultures. 

The  tubercle  bacilli  will  be  discussed  under  the  head  of  Tuberculosis  of 
the  Bladder.  In  themselves  they  are  not  able  to  cause  general  cystitis,  but  they 
Strongly  predispose  to  mixed  infection. 

Bilharzia.  a  parasitic  disease  indigenous  to  the  tropics,  especially  Egypt,  is 
caused  by  the  Schistosomum  haematobium  (Bilharz").  The  early  stages  of  the 
disease  in  the  bladder  are  characterized  by  small  elevations  of  the  mucosa 


490  GENITO-URINARY  SURGERY 

especially  on  the  trigonum,  the  only  symptom  being  a  painless  haematuria. 
Later  the  walls  of  the  bladder  become  enormously  thickened,  usually  containing 
calcareous  deposits,  while  the  interior  of  the  viscus  is  more  or  less  completely 
filled  with  a  sloughing,  papillomatous  mass,  in  which  are  mingled  large  quantities 
of  blood  and  pus.  At  this  stage  there  is  frequent,  painful  urination,  sometimes 
complete  retention  of  urine;  tfie  external  genitalia,  ureters,  and  kidneys  have 
also  commonly  become  extensively  involved. 

Diagnosis  is  made  from  the  cystoscopic  appearance,  and  the  finding  of  the 
typical  ova  in  the  urine. 

Treatment  is  entirely  symptomatic. 

Germs  exert  their  injurious  action  upon  the  bladder-tissue  either  directly 
or  through  their  ptomaines.  The  inflammation  they  produce  is  increased  by 
the  ammoniacal  fermentation  of  the  urine  which  they  bring  about.  This  fer- 
mentation is  due  to  the  decomposing  action  of  microbes  upon  urea,  ammonium 
carbonate  being  formed.  This  converts  the  pus  into  a  ropy,  gelatinous  mass, 
renders  the  urine  markedly  alkaline,  and  makes  it  thick,  foul,  and  ammoniacal. 
The  proteus  group  produce  this  ammoniacal  fermentation ;  the  urine  in  cases  of 
cystitis  due  to  most  other  organisms  is  usually  acid. 

Cystitis  has  for  its  seats  of  predilection  the  trigonum.  It  is  in  this  region 
particularly  that  the  most  pronounced  lesions  are  usually  found,  even  though 
the  entire  vesical  mucous  membrane  is  involved. 

Superficial  or  catarrhal  and  ulcerative  cystitis  in  its  acute  form  is 
characterized  by  a  reddened,  oedematous,  ecchymotic  mucous  membrane  the 
vessels  of  which  are  markedly  engorged.  Erosions  or  distinct  ulcerations  may 
develop.  Exceptionally  shreds  of  necrotic  mucous  membrane  are  passed.  The 
urine  is  usually  acid,  and  contains  pus  and  much  bladder  epithelium. 

Vesical  ulceration  occurs  in  the  following  forms:  (a)  traumatic;  (b)  in- 
flammatory, including  simple  pyogenic  and  tuberculous;  (c)  malignant,  and  (d) 
simple  or  solitary,  described  also  as  embolic,  perforating,  or  idiopathic.  The 
last  group,  described  by  Fenwick,  is  not  definitely  understood,  and  has  prob- 
ably been  often  mistaken  for  tuberculosis.  These  ulcers  are  usually  single,  and 
located  to  the  inner  side  of  the  ureteral  orifice  on  the  posterior  wall,  but  not 
actually  on  the  trigonum.  They  are  comparable  to  gastric  ulcers,  and  may 
perforate. 

When  superficial  cystitis  becomes  chronic,  reddening  of  the  thickened  mucous 
membrane  is  no  longer  pronounced.  Indeed,  this  may  assume  a  yellowish  hue 
with  prominent  veins  and  areas  of  exfoliation  colored  gray-white  by  thin  layers 
of  pus  or  urinary  salts.  From  the  oedematous  and  congested  mucous  mem- 
brane small  polyps  may  grow,  and  the  inner  surface  of  the  bladder  is  often 
trabeculated  from  muscular  hypertrophy. 

The  urine  is  generally  alkaline;  when  markedly  so  from  ammoniacal  fer- 
mentation, there  is  often  found  overlying  the  mucous  membrane  a  dirty-whitish 
deposit  of  muco-pus. 

Interstitial  cystitis  exhibits  the  mucous  membrane  lesions  of  a  superficial 
inflammation.  The  inflammation  extends  more  deeply,  however,  involving 
particularly  the  connective  tissue,  but  not  entirely  sparing  the  muscular  fibres. 
From  the  inflammatory  infiltration  the  folds  of  the  mucosa  become  prominent, 


SURGERY  OF  THE  BLADDER 


491 


causing  ridges  to  be  formed,  which  are  readily  felt  on  exploration  by  a  sound. 
The  bladder-walls  may  become  enormously  thickened.  Small  abscesses  develop 
in  the  submucous  connective  tissue  or  in  the  muscular  coats.  These  abscesses 
commonly  open  into  the  vesical  cavity,  leaving  diverticula  which  are  slow  to 
heal.  Exceptionally  such  abscesses  extend  outward,  involving  the  perivesical 
tissues  and  resulting  in  localized  pelvic  cellulitis  or  in  peritonitis.  If  the  active 
disease  is  arrested,  organization  and  cicatrization  take  place,  producing  more 
or  less  distortion  and  contraction,  sometimes  sufficient  to  lessen  greatly  the 
vesical  capacity  (Fig.  244). 

Localized  Cystitis. — Under  this  heading  Geraghty^  describes  a  variety 
of  lesions,  all  characterized  by  their  discrete  character,  but  varying  from  a 


Fig.  244. — Interstitial  cystitis.  Vesical  cavity  is  irregular 
in  shape;  M,  mucosa,  roughened  and  leathery;  S,  sacculation; 
W,  wall  of  viscus  greatly  thickened;  .U,  urethra.  (No.  69-5-6, 
Museum  of  Pathology,  University  of  Pennsylvania.) 

simple  hypersemia  to  ulceration.  The  most  deeply  seated  lesions  give  the 
cystoscopic  appearance  of  puckered  and  scarred  pale  areas;  in  such  cases  the 
infiltration  extends  deeply  into  the  muscular  coat,  and  cure  can  only  be  effected 
by  radical  measures  (excision  or  deep  cauterization). 

Cystitis  Cystica  is  a  nodular,  glandular  condition  characterized  by  the 
appearance  of  small  nodules  disseminated  over  the  bladder  surface  resembling 
tubercles.  This  comparatively  rare  affection  of  the  bladder,  an  entity  in  itself, 
is  merely  classified  under  "  Cystitis"  for  the  sake  of  convenience  (Fig.  245). 
The  nodules  are  strictly  of  epithelial  formation  of  a  pseudo-glandular  type;  in 
cross-section  they  are  irregularly  circular  or  oval  in  form  and  are  lined  by  epi- 
thelial cells.     They  are  filled  with  fluid  of  mucoid  or  colloid  character,  con- 

^"  Surgery,  Gynecology  and  Obstetrics,"  1917. 


492  GENITO-URINARY  SURGERY 

taining  desquamated  epithelial  cells  and  detritus.  The  cysts  vary  considerably 
in  size,  being  small  when  deep-seated,  larger  and  distended  near  the  surface 
(Fig.  246).  The  theory  has  been  advanced  that  these  epithelial  nests  are 
primarily  inclusions  by  the  connective  tissue  of  the  overlying  proliferate  epi- 
thelium. Clinically,  the  condition  is  of  importance,  inasmuch  as  these  cystic 
formations  are  prone  to  undergo  carcinomatous  degeneration. 

Membranous  cystitis,  variously  described  as  exfoliative,  croupous,  diph- 
theritic, and  desquamative,  is  characterized  by  the  discharge  through  the  urethra 
or  through  a  wound  of  the  bladder  of  flakes,  masses,  or  complete  moulds  of  the 


Fig.  245.^— Cystitis  cystica.  D,  part  of  the  vesical 
mucosa  has  undergone  carcinomatous  degeneration; 
C,  area  of  epitheUal  cystic  formation.  (No.  1211. 
From  the  Laboratory  of  Surgical  Pathology,  Univer- 
sity of  Pennsylvania.) 

bladder,  made  up  of  tough,  fibrinous,  structureless  membrane  containing  the 
remains  of  broken-down  epithelium. 

Stein  states  that  of  fifty  reported  cases,  forty-five  occurred  in  women,  and 
mostly  in  connection  with  labor  or  with  serious  uterine  troubles.  The  pathology 
seems  to  vary  somewhat  in  different  cases.  X^us,  Cabot,  in  practising  supra- 
pubic cystotomy,  peeled  off  a  thick  membrane  composed  almost  entirely  of 
epithelium.  Adami  holds  that  true  exfoliative  cystitis  is  practically  a  necrosis  of 
the  inner  layers  of  the  bladder. 

Gangrenous  cystitis  is  characterized  by  sloughting  of  the  mucous  and 
muscular  coats  of  the  bladder.  It  is  occasionally  noted  in  acute  septic  processes, 
in  cancer  of  the  bladder,  and  as  a  sequel  to  extensive  trauma. 

Pericystitis  is  separately  considered. 

Symptoms  of  Cystitis. — There  are  no  subjective  symptoms  which  point 


SURGERY  OF  THE  BLADDER 


493 


exclusively  to  cystitis — pain,  frequent  micturition,  and  pus  in  the  urine,  symp- 
toms usually  considered  diagnostic  of  bladder-inflammation,  being  present  when 
the  prostatic  urethra  alone  is  involved. 

The  symptoms  of  cystitis  are — 1,  pyuria;  2,  frequent  urination;  3,  pain; 
4,  muscular  spasm;   5,  hsematuria;  6,  fever. 

Pyuria. — With  pus  there  is  frequently  found  blood,  and  there  is  always  a 
superabundance  of  mucus  and  bladder  epithelium.  When  the  urine  is  acid, 
there  settles  from  it  on  standing  a  white  sediment  of  pus,  and  over  this  a 
cloud  of  mucus.  When  the  urine  is  neutral  or  alkaline,  particularly  when 
ammoniacal  decomposition  has  taken  place,  there  is  often  a  viscid,  ropy  deposit 
of  mucopus.  In  chronic  cases  micturition  may  terminate  by  the  expulsion  of 
almost  pure  mucopus. 

Microscopical  examination  of  the  sediment  shows  abundant  bladder  epithe- 
lium, pus,  often  blood,  microorganisms,  and 
in  alkaline  urine  triple  phosphate  crystals. 

Frequent  Urination. — This  symptom 
develops  partly  because  the  bladder-walls 
are  abnormally  sensitive  to  tension,  partly 
because  the  prostatic  urethra  is  inflamed 
and  hypersensitive.  Frequent  urination  is 
aggravated  by  the  erect  posture,  by  bodily 
activity,  by  jolting  or  jarring,  and  by  any 
of  the  causes  which  tend  to  increase  conges- 
tion of  the  prostatic  urethra.  At  times  the 
patient  is  forced  to  micturate  every  few 
minutes,  and  is  absolutely  unable  to  retain 
his  water  when  the  desire  is  felt;  usually, 
however,  it  can  be  retained  one  or  two  hours. 

The  frequent  urination  which  so  often 
accompanies  chronic  cystitis,  particularly 
when  there  is  a  mechanical  obstruction  to 
the  free  passage  of  urine,  may  occasion  an  enormous  hypertrophy  of  the  muscular 
trabeculae,  with  a  sacculation  of  the  weaker  portions  of  the  vesical  walls  lying 
between  these  interlacing  fibres.  Bladders  thus  affected  are  most  difficult  to 
cleanse  of  the  ammoniacal  urine. 

When  there  is  frequent  urination  and  much  straining,  there  may  be  some 
kidney  albuminuria  due  to  congestion  of  these  organs.  Usually  the  quantity 
of  albumen  in  the  urine  is  proportionate  to  the  amount  of  blood  and  pus  which 
it  contains.  Exceptionally  in  chronic  cases  there  may  be  a  leakage  through 
patches  denuded  of  the  surface  epithelium. 

Pain. — This  in  the  acute  cases  is  constant,  with  exacerbations  taking  the 
form  of  intense  burning,  with  irresistible  desire  to  pass  water  and  violent  strain- 
ing (tenesmus).  It  is  usually  aggravated  by  the  act  of  micturition,  and  is 
more  or  less  relieved  after  the  bladder  is  emptied.  Exceptionally,  as  in  the 
case  of  stone  and  acute  gonorrhoeal  prostatocystitis,  the  pain  is  most  intense  after 
micturition.  It  is  felt  in  the  prostate  and  bladder,  and  radiates  from  there  to 
the  hypogastric  region,  the  sacrum,  the  rectum,  the  end  of  the  penis,  and  down 


Fig.  246. — Cystitis  cystica.  Photo- 
micrograph showing  cyst-formation  and 
papillary  outgrowth  of  mucosa. 


494  GEXITO-URIXARY  SURGERY 

the  inner  surfaces  of  the  thighs.  In  very  acute  cases  when  there  is  prostato- 
c\-stitis  the  patient  is  compelled  almost  constantly  to  make  violent  and  most 
painful  straining  efforts  at  urination,  with  the  evacuation  of  but  a  few  drops  of 
blood-stained  water  at  a  time  (strangury). 

Muscular  Spasm. — As  a  result  of  inflammation  reflex  excitability  is  mark- 
edly exalted.  It  is  to  the  overaction  of  the  sphincter  muscles  that  much  of 
the  pain  in  C3'stitis  is  due.  These  are  thrown  into  tonic  contraction,  or  sphinc- 
terismus, thus  increasing  congestion  and  exciting  pain,  very  much  as  do  the 
anal  sphincters  in  acute  proctitis.  By  their  tonic  contraction  they  resist  the 
attempts  of  the  detrusors  to  empty  the  bladder,  yielding  only  after  long  effort, 
and  then  but  partly,  thus  occasioning  strangur}-;  or  the  contraction  may  be  so 
obstinate  that  there  is  complete  retention  of  urine.  Very  frequently  the  tonic 
spasm  is  replaced  by  clonic  contractions,  which  suddenly  shut  off  the  stream 
when  it  is  started,  especially  when  the  last  few  drops  are  being  voided.  From 
the  closeh^  connected  nerve-supph',  the  sphincter  ani  sometimes  participates 
in  this  tonic  contraction,  thus  adding  to  the  distress. 

Hasmaturia. — The  passage  of  almost  pure  blood,  especially  when  it  comes 
at  the  end  of  urination,  is  characteristic  of  inflammation  of  the  prostatic  urethra 
rather  than  of  cystitis.  After  micturition  is  completed  the  bleeding  may  still 
continue  from  this  region  and  flow  back  into  the  bladder,  rendering  the  urine 
alkaline  and  predisposing  it  to  ammoniacal  fermentation,  with  marked  aggrava- 
tion of  the  C3'stitis.  From  the  bladder-walls  in  hyperacute  cases  there  is  usually 
some  bleeding.    This  is  slight,  and  the  blood  is  intimately  mixed  with  the  urine. 

Fever. — In  the  beginning  of  an  acute  cystitis,  fever  and  the  associated  symp- 
toms of  depression,  nausea  and  constipation,  are  frequently  observed.  Fever 
is  not  a  usual  symptom  of  chronic  cystitis.  \\Tien  it  reaches  a  high  grade,  and 
is  prolonged  and  parox3'smal  in  type,  it  may  be  taken  as  a  sign  that  cystitis  is 
not  the  only  cause.  In  these  cases  examination  usualty  shows  involvement  of 
the  prostate  in  acute  cases — an  accompam'ing  pyelonephritis  in  the  chronic  ones. 

Diagnosis. — Frequent  urination,  pain,  and  pus  in  the  urine  are  of  them- 
selves not  enough  to  make  the  diagnosis  of  cystitis  complete. 

In  cases  of  chronic  inflammation  there  may  be  no  symptoms  except  pyuria. 
\Mien,  together  with  some  or  all  of  the  s^^mptoms  given  above,  the  bladder  is 
tender  on  suprapubic  and  rectal  palpation,  when  the  urine  passed  in  three  por- 
tions shows  greatest  pus-turbidit\^  in  the  last,  when  the  flat  bladder  epithelium 
is  very  abundant,  when  intravesical  injections  show  that  the  bladder  is  hyper- 
sensitive to  tension,  and  when  the  urine  at  the  time  of  being  passed  is  ropy 
and  ammoniacal,  the  diagnosis  of  cystitis  can  be  made  confidently.  The  further 
diagnosis  in  regard  to  the  seat  of  the  inflammation,  its  nature  and  extent,  and 
the  presence  or  absence  of  complicating  renal  infection  is  made  by  cystoscopy 
and  b}^  ureteral  catheterization. 

Progxosis  of  Cystitis. — Provided  there  is  no  lesion  which  tends  in- 
definitely to  prolong  vesical  congestion,  the  prognosis  of  acute  cystitis  is  favor- 
able. The  inflammation  which  frequently  accompanies  stone  or  tight  stricture  of 
the  urethra,  or  even  enlarged  prostate,  can  be  completely  cured  by  removal  of 
the  exciting  cause.  Cystitis  due  to  gonorrhoea  or  rough  instrumentation  usually 
runs  a  rapid   and   favorable  course.     It  often  happens,  however,   that  some 


SURGERY  OF  THE  BLADDER  495 

infection  of  the  mucosa  remains,  which  is  stimulated  to  renewed  activity  when- 
ever normal  emptying  of  the  bladder  is  interfered  with,  or  when  sexual  or 
alcoholic  excess  or  intercurrent  disease  causes  pelvic  congestion  and  irritation. 
The  cure  is  probably  more  often  relative  than  absolute,  since  it  is  considered 
established  when  micturition  is  accomplished  normally  and  when  the  urine  is 
apparently  clear. 

The  final  conclusive  proof  of  cure  should  be  founded  upon  the  results  of 
microscopic  examination  of  the  urine.  If  the  centrifuged  sediment  of  twenty- 
four  hours'  urinary  secretion  is  found  to  be  free  from  pus,  the  patient  may  be 
considered  cured.  If,  on  the  contrary,  pus  is  found,  even  though  it  be  in  small 
quantities,  perhaps  scarcely  enough  to  form  shreds,  some  focus  of  infection 
stili  remains,  and  is  liable  to  light  up  an  acute  iniiammation  under  favoring 
circumstances. 

As  a  rule,  though  the  active  symptoms  may  be  subdued  or  may  entirely 
disappear,  some  suppuration  persists. 

It  may  happen  that  from  infiltration  of  the  bladder-walls,  followed  by  fibroid 
change  and  contraction,  the  vesical  cavity  becomes  greatly  reduced,  so  that  the 
bladder  can  contain  but  a  few  ounces  at  a  time.  More  frequently,  particularly 
in  the  case  of  prostatics,  there  is  dilatation  with  an  incurably  thickened  sup- 
purating mucous  membrane. 

In  its  relation  to  involvement  of  the  kidneys,  and  consequently  to  the  life 
of  the  patient,  the  prognosis  of  acute  and  chronic  cystitis  is  somewhat  different. 

Lipowski  states  that  the  conditions  favoring  ascending  infection  are  moderate 
retention  and  a  strong,  irritable  bladder,  which  drives  urine  back  into  the  ureter 
af  the  'moment  the  orifice  of  this  canal  is  opened  to  expel  its  contents.  These 
conditions  are  fulfilled  in  cases  of  stricture,  hypertrophied  prostate,  acute  in- 
^flainmation,  and  spastic  affections  during  the  first  period  of  cystitis.  The 
inflammation  markedly  increases  the  irritability  of  the  yet  strong  bladder- 
muscles.  Hence  it  would  seem  to  follow  that  the  greatest  danger  of  kidney 
infection  from  the  bladder  exists  in  the  early  stages  of  cystitis;  later,  when  the 
suHmucous  and  muscular  coats  are  infiltrated  and  the  vesical  contractions  are 
feeble,  intravesical  tension  is  not  sufficiently  high  to  overcome  that  exerted 
by  the  stream  of  urine  descending  from  the  kidney.  Tuberculous  cystitis, 
according  ot  Lipowski,  forms  an  exception  to  this  rule. 

Treatment  of  Cystitis. — From  what  has  been  said  concerning  the  cause 
of  cystitis,  it  is  plain  that  the  prevention  of  this  disease  depends  upon  the 
avoidance  of  local  congestion  and  of  the  entrance  of  germs  into  the  bladder. 

Before  entering  upon  the  treatment  of  a  case  of  cystitis  the  urine  should 
be  examined  for  the  purpose  of  determining  its  reaction  and  the  degree  of 
acidity  or  alkalinity  as  indicated  by  titration  with  a  decinormal  solution  of 
sodium  hydrate  or  hydrochloric  acid,  and  of  recognizing  the  presence  of  any 
substances  irritating  to  the  vesical  mucosa,  as  oxalate  or  uric  acid  crystals. 
The  removal  of  any  urinary  irritation  is  essential  to  the  speedy  cure  of  the 
cystitis. 

Local  congestion  is  avoided  by  attention  to  the  rules  of  hygiene.  Chilling 
of  the  surface,  wet  feet,  prolonged  standing,  elaborate  meals,  highly  seasoned 
foods,  pastry,  sweets,  alcohol,  and  rhubarb  are  to  be  avoided.     Rest  in  bed  is 


496  GENITO-URINARY  SURGERY 

not  desirable;  indeed,  in  cases  of  partial  urinary  retention  it  seems  to  favor 
rather  than  lessen  pelvic  congestion.  Regular  daily  exercise  in  the  open  air,  such 
as  driving,  walking,  or  riding  the  horse  or  bicycle,  in  accordance  with  the  strength 
of  the  patient,  is  to  be  commended.  The  diet  must  be  so  regulated  that  diges- 
tion is  perfectly  performed;  even  slight  gastric  or  intestinal  disorders  render 
the  urine  distinctly  irritating. 

Usually  diluent  drinks  are  serviceable,  particularly  at  night,  since  the  urine 
is  most  strongly  acid  during  the  small  hours.  Natural  mineral  waters  may  be 
ordered  in  accordance  with  the  dyscrasia  of  the  patient.  Thus,  lithia  water 
would  be  indicated  in  the  gouty  or  rheumatic,  ferruginous  waters  in  the  anaemic 
or  in  those  subject  to  looseness  of  the  bowels. 

Careful  attention  should  be  given  to  the  condition  of  the  skin.  The  patient 
should  bathe  daily  in  either  hot  or  cold  water,  according  to  preference.  This 
bath  should  be  followed  by  vigorous  friction.  The  sweating-box  described  under 
the  treatment  of  syphilis  is  particularly  serviceable,  and  may  be  used  daily  when 
there  is  no  idiosyncrasy  and  when  it  does  not  produce  weakness  or  debility.  The 
feelings  of  the  patient  will  be  the  best  guide  in  deciding  on  this  course  of  treat- 
ment.    The  sweat  should  be  followed  by  a  cool  sponging  and  vigorous  friction. 

Regular  evacuation  of  the  bowels  is  a  matter  of  cardinal  importance.  It 
has  been  shown  experimentally  that  rectal  obstruction  is  almost  immediately 
followed  by  the  appearance  of  enormous  numbers  of  colon  bacilli  in  the  urine, 
coming  either  through  the  kidneys  or  conceivably  directly  from  the  thin  inter- 
vening walls.  A  daily  bowel  movement  is  best  procured  by  exercise  and  diet. 
If  these  means  are  not  efficient,  mild  salines,  such  as  Hunyadi  water,  may  be 
administered  in  the  early  morning,  or  rectal  enemata  of  normal  saline  solution 
may  be  given.  The  nightly  ingestion  of  half  to  one  ounce  of  paraffin  oil  is 
generally  beneficial. 

WTien  there  are  local  causes  for  reflex  irritability,  as  hemorrhoids,  varicocele, 
tight  prepuce,  or  narrow  meatus,  these  should  receive  appropriate  surgical  treat- 
ment. Urethral  causes  of  bladder-irritability  or  of  partial  retention  of  urine, 
such  as  stricture  of  either  large  or  small  calibre,  should  be  relieved  as  promptly 
as  possible.  Furthermore,  many  cases  of  cystitis  are  kept  up  by  repeated  re- 
infection from  such  sources  as  the  kidney  pelves,  the  seminal  vesicles,  the  pros- 
tate, occasionally  the  utricle. 

Acute  cystitis,  or  violent  congestion  typified  by  cantharidal  poisoning,  is 
treated  by  hot  baths,  rest  in  bed,  elevation  of  the  pelvis,  and  thorough  evacuation 
of  the  lower  bowel,  best  procured  by  salines  and  cold  enemata  of  salt  water. 

For  the  relief  of  the  frequent  painful  urination  belladonna  and  opium  sup- 
positories are  indicated.  These  should  be  repeated  hourly  till  they  accomplish 
the  purpose  for  which  they  are  given  (extract  of  opium,  one-half  grain;  extract 
of  belladonna,  one-fourth  grain).  Rectal  applications  through  a  catheter  by 
means  of  a  piston  syringe,  of  fifteen  to  thirty  grains  of  antipyrin  and  ten  to 
twenty  drops  of  laudanum  in  one-half  ounce  of  water,  are  more  useful  and  less 
disadvantageous  than  morphine  or  opium  suppositories.  Hot  compresses  should 
be  applied  to  the  entire  abdomen,  and  should  be  changed  frequently.  Diluents 
and  sedatives  should  be  given  by  the  mouth.  If  there  is  fever  with  consequent 
strongly  acid  urine,  to  the  copious  draughts  of  water  should  be  added  potassium 


SURGERY  OF  THE  BLADDER  497 

citrate  or  acetate,  in  doses  of  ten  grains  six  times  daily,  or  spirit  of  nitrous 
ether  in  drachm  doses  hourly,  or  liquor  potassii  citratis  may  be  administered  in 
tablespoonful  doses  well  diluted  every  one  or  two  hours.  Salol  and  boric  acid 
should  always  be  given  for  the  purpose  of  rendering  the  urine  slightly  antiseptic. 
When  the  symptoms  are  unusually  severe,  patients  often  assume  the  knee-elbow 
position,  since  thus  the  pressure  of  the  abdominal  viscera  is  taken  from  the  blad- 
der and  venous  engorgement  is  lessened.  This  position  is  serviceable,  and  should 
be  advised  when  it  is  not  spontaneously  assumed. 

When  the  symptoms  are  purely  the  result  of  congestion — i.e.,  when  there 
is  no  vesical  infection — all  intravesical  manipulations  should  be  avoided,  unless 
retention  threatens,  though  pain  may  be  relieved  promptly  and  for  several  hours 
by  the  instillation  of  fifteen  drops  of  a  five  per  cent,  solution  of  eucaine.  In 
cases  of  gonorrhoeal  prostatocystitis  where  the  inflammation  is  limited  to  the 
prostatic  urethra  and  portion  of  the  trigonum  nearest  the  vesical  orifice,  an 
instillation  of  ten  drops  of  a  five  per  cent,  solution  of  silver  nitrate  may  give 
almost  immediate  relief,  or  it  may  make  still  more  intolerable  the  suffering  of 
the  patient. 

The  bleeding  of  acute  inflammation  is  usually  slight,  and  is  often  of  ad- 
vantage, since  it  lessens  congestion;  it  requires  no  special  treatment. 

Should  retention  supervene,  if  it  is  entirely  due  to  spasm  and  congestion, 
an  attempt  should  be  made  to  reheve  it  by  a  hot  general  bath,  the  patient 
being  directed  to  micturate  while  still  in  the  tub.  Hot  compresses  or  turpentine 
stupes  to  the  abdomen  and  full  doses  of  opium  and  hyoscyamus  or  belladonna 
are  also  indicated.  When  retention  is  complete  and  distention  pronounced, 
there  should  be  no  hesitation  in  employing  the  catheter,  nitrous  oxide  being 
given  if  this  manipulation  is  excessively  painful.  The  catheter  may  be  left 
in  place  for  several  days,  until  the  hyperacute  symptoms  have  subsided  (see 
p.  73). 

In  the  course  of  a  week  to  ten  days  the  acute  inflammation  will  subside, 
and,  provided  there  are  no  local  conditions  which  tend  indefinitely  to  prolong 
congestion,  convalescence  may  be  complete.  Usually  the  disease  becomes 
chronic,  and  may  thus  continue  for  years,  giving  rise  to  no  symptoms  other 
than  a  small  quantity  of  pus  in  the  urine,  but  being  subject  to  acute  exacer- 
bations. 

Treatment  of  chronic  cystitis  will  not  be  successful  unless  the  predisposing 
causes,  such  as  urethral  obstruction,  stone,  and  tumor,  are  removed.  The  diet 
should  be  so  regulated  that  the  food  is  thoroughly  digested  and  the  gastro- 
intestinal tract  kept  free  from  irritation;  highly  seasoned  articles,  desserts,  and 
alcohols  are  in  general  to  be  avoided.  The  natural  mineral  waters  are  useful 
as  diluents,  and  may  be  taken  between  meals.  Saline  diuretics — and  among 
these  potassium  citrate  is  the  most  valuable — should  be  given,  well  diluted,  in 
quantities  sufficient  to  keep  the  urine  nearly  neutral  in  reaction.  In  the  absence 
of  a  rheumatic  diathesis,  and  particularly  where  there  is  an  associated  anaemia, 
the  ferruginous  mineral  waters  are  of  use. 

Of  the  long  list  of  drugs  used  by  the  mouth  comparatively  few  have  any  real 
value.  Benzoic  acid  often  does  good  when  the  urine  is  markedly  alkaline. 
It  may  be  given  in  five-  to  ten-grain  doses  six  times  a  day.  The  dose  is 
32 


498  GENITO-URINARY  SURGERY 

regulated  by  the  effect  upon  the  urine.  Acid  sodium  phosphate  in  half-drachm; 
doses  every  three  hours  is  a  useful  drug  for  acidifying  the  urine  and  relaxing 
the  bowels.  Hexamethylenamine  is  sometimes  useful  an  a  urinary  antiseptic 
when  the  urine  is  distinctly  acid,  in  doses  of  not  less  than  forty  grains  a  day; 
it'  is  useless  when  the  urine  is  either  neutral  or  alkaline.  Care  must  be  used 
that  it  does  not  cause  irritation  of  the  bladder  or  kidneys.  The  balsams  are 
extremely  useful  in  both  subacute  and  chronic  cystitis.  Santyl,  an  ester  of 
sandalwood  oil,  is  particularly  serviceable,  but  should  be  given  in  fairly  full 
doses. 

Of  the  many  other  drugs  which  have  been  recommended  and  which  are 
commonly  employed,  perhaps  the  most  useful  are  pichi  extract  five  grains  every 
two  hours  in  capsules;  cantharides  in  drop  doses  every  one  or  two  hours  as 
a  stimulant  in  extremely  chronic  cases;  turpentine  five  to  fifteen  drops  in  emul- 
sion every  three  hours;  oil  of  eucalyptus  five  to  ten  drops  in  emulsion  every 
two  hours;  fluid  extract  of  buchu  or  uva  ursi  in  drachm  doses  every  two  or 
three  hours;  arbutin  in  doses  of  three  to  five  grains  three  to  six  times  daily. 

Generally,  if  predisposing  causes  are  removed,  and  the  urine  rendered  un- 
irritating,  stimulant,  and  slightly  antiseptic,  so  that  ammoniacal  fermentation 
does  not  take  place,  the  symptoms  rapidly  improve,  and  the  patient  recovers. 
If,  however,  these  milder  hygienic  and  medicinal  methods  fail  and  free  vesical 
suppuration  continues,  local  treatment  is  indicated.  This  may  be  applied  either 
by  instillation  or  by  irrigation. 

The  method  of  employing  instillation  has  been  described  already  under  the 
treatment  of  posterior  urethritis.  Irrigations  are  practised  with  a  fountain 
syringe  fitted  to  either  a  short  urethral  nozzle  or  a  soft  rubber  catheter  of  com- 
paratively full  size.  Irrigations  with  a  short  urethral  nozzle  may  be  employed 
when  the  vesical  tonicity  is  good  and  the  bladder  has  the  power  of  completely 
and  painlessly  evacuating  its  contents.  In  chronic  cystitis  this  condition  is  rare: 
hence  the  method  of  choice  is  usually  that  with  the  catheter. 

Instillations  are  indicated  when  inflammation  is  particularly  severe  at  or 
about  the  neck  of  the  bladder.  This  is  usually  shown  by  the  symptoms,, 
strangury  being  always  most  pronounced  when  inflammation  is  thus  located. 
These  instillations  act  directly  upon  the  prostatic  urethra  and  the  neck  of  the 
bladder.  They  may  at  first  seem  to  aggravate  tenesmus  and  pain,  but  this  is 
shortly  followed  by  marked  relief.  The  solutions  of  choice  are  those  of  silver 
nitrate  with  a  maximum  strength  of  five  per  cent.  It  is  well  to  begin  with  a 
one-half  per  cent,  solution  and  gradually  increase  the  strength  till  ihe  symptoms 
are  relieved. 

Minet  advises  instillations  two  or  three  times  a  week  of  two  to  four  cubic 
centimetres  of  two  per  cent,  aqueous  solution  of  pyrogallic  acid  to  relieve  painful 
frequency  of  micturition. 

Instillations  are  repeated  every  second,  third,  or  fourth  day,  in  accordance 
with  the  reaction  they  excite.  The  immediate  pain  they  cause  may  be  lessened 
by  preceding  them  by  an  application  of  eucaine.  When  it  is  desired  to  affect 
a  larger  surface  of  the  bladder,  two  to  four  drachms  may  be  employed.  The 
strength  of  the  silver  solution  when  it  is  thus  used  should  not  be  more  than  one 
per  cent.     When  the  treatment  is  inaugurated  it  is  well  to  begin  with  half  a 


SURGERY  OF  THE  BLADDER  499 

grain  to  the  ounce.  Silver  nitrate  instillations  are  particularly  serviceable  in 
gonorrhoeal  cystitis,  and  in  those  chronic,  non-tuberculous  forms  of  inflammation 
which  are  not  dependent  upon  urethral  obstruction  and  retention. 

SubHmate  instillations  are  useful  in  tuberculous  cystitis.  They  also  render 
good  service  in  the  inflammation  due  to  gonococci,  colon  bacilli,  and  ordinary 
pyogenic  microbes.  This  method  of  treatment  was  first  popularized  by  Guyon, 
who  reported  extraordinarily  successful  results.  The  quantity  injected  into 
the  bladder  should  be  from  one  to  two  drachms,  and  that  into  the  posterior 
urethra  from  five  to  fifteen  drops.  Weak  solutions  are  first  employed  (1  to 
4000),  and  the  strength  is  gradually  increased  (1  to  500).  These  instillations 
may  be  repeated  every  second  or  third  day,  and  should  be  preceded  by  irrigations 
unless  the  bladder  is  extremely  irritable. 

Irrigations  are  given  with  strict  attention  to  cleanliness.  The  quantity  in- 
jected varies  in  accordance  with  the  capacity  and  irritability  of  the  bladder.  It 
is  a  good  rule  not  to  inject  a  sufficient  bulk  of  fluid  to  cause  pain  from  tension. 

The  most  efficient  irrigation  is  that  of  the  silver  salts.  The  solution  employed 
varies  in  strength  from  1 :  10,000  to  1 :  500.  In  extremely  chronic  cases  much 
stronger  solutions  than  these  are  not  only  tolerated  but  are  beneficial.  The 
urine  is  first  passed.  The  bladder  is  then  irrigated  with  boiled  water  until  this 
comes  away  clear;  finally  one  or  two  ounces  of  the  silver  solution  are  thrown 
in  and  allowed  to  escape  almost  immediately.  Strong  silver  irrigations  are 
repeated  daily  or  every  second  or  third  day,  in  accordance  with  the  violence 
of  reaction.  When  they  excite  severe  pain  and  apparently  aggravate  symp- 
toms— and  this  is  particularly  likely  to  occur  in  tuberculous  cystitis — other 
antiseptics  should  be  employed.  After  silver  nitrate  the  most  efficient  lotions 
are  those  of  potassium  permanganate  (1:  6000  to  1:  500),  boric  acid  (five  to 
fifteen  grains  to  the  ounce),  saHcylic  acid  (1:  1000  to  1:  10,000),  and  ichthyol. 
(1:  1000  to  1:50,  in  normal  saline  solution).  When  even  the  weakest  of  these 
antiseptics  occasions  pain  and  marked  reaction,  and  when  it  is  certain  that 
these  sequelae  are  not  due  to  bladder-tension  incident  to  the  injection  of  too 
great  a  quantity  at  one  time,  recently  boiled  nine-tenths  per  cent,  sodium 
chloride  solution  may  be  employed. 

It  should  be  clearly  understood  that  in  cases  of  chronic  cystitis  the  bladder 
mucosa  is  infected  not  only  upon  its  surface  but  also  in  its  depth,  and  that 
no  antiseptic  can  reach  germs  which  are  embedded  in  the  tissues.  The  function 
of  lavage  is  not  to  render  the  bladder-wall  sterile,  but  rather  to  remove  decom- 
posing pus  and  urine,  to  inhibit  or  destroy  those  germs  which  lie  upon  the 
surface,  to  stimulate  healthfully  the  chronically  engorged  vesical  walls,  and 
to  leave  in  the  bladder  a  residuum  which  will  prevent  further  fermentation  of 
the  urine,  with  its  irritating  effect  upon  the  mucosa.  It  is  therefore  well,  after 
having  practised  irrigation,  to  leave  from  half  a  drachm  to  an  ounce  of  anti- 
septic solution  in  the  bladder.  This  is  particularly  indicated  when  evacuation 
of  the  last  few  drachms  of  urine  is  painful. 

No  rule  can  be  given  as  to  the  number  of  irrigations  which  are  indicated. 
Where  there  is  profuse  suppuration  with  rapid  decomposition,  ammonuria, 
and  retention,  the  bladder  should  be  washed  out  at  least  twice  daily,  and  often 
this  process  can  be  advantageously  repeated  three  or  four  times.  Where  the 
cystitis  is  slight  in  grade  and  the  urine  is  not  decomposed,  irrigations  may  be 


500  GENITO-URINARY  SURGERY 

practised  every  two  or  three  days.    Daily  irrigation  at  least  is  generally  required. 

When  in  spite  of  instillations  and  irrigations,  or  because  of  pain,  spasm,  and 
undue  reaction,  these  methods  of  treatment  are  not  practicable,  the  cystitis 
becoming  steadily  worse,  and  constitutional  symptoms  developing,  permanent 
catheterization  is  indicated.  The  technique  of  this  method  is  fully  described 
under  the  treatment  of  retention  from  prostatic  obstruction.  If  the  catheter  is 
properly  held  in  place,  the  bladder  is  constantly  drained  and  thus  put  at  rest. 
Through  this  catheter  are  practised  irrigations  with  the  solution  which  excites 
least  inflammatory  reaction. 

The  use  of  autogenous  bacterins  is  sometimes  a  useful  adjuvant,  especially 
in  subacute  and  chronic  cases  resistant  to  other  treatment. 

In  the  treatment  of  localized  cystitis  Geraghty  states  that  irrigations  usually 
suffice  for  the  cure  of  lesions  affecting  only  the  mucosa  and  submucosa.  When 
there  is  in  addition  mild  involvement  of  the  muscularis  he  has  had  good  success 
by  applying  ten  to  twenty  per  cent,  solutions  of  silver  nitrate  by  means  of  a 
ureteral  catheter  cut  off  at  the  eye  directly  to  the  lesions,  the  remainder  of 
the  mucosa  being  protected  by  using  saline  solution  as  the  distending  medium; 
more  obstinate  lesions  he  has  treated  with  the  solid  stick  fused  on  the  end  of 
a  catheter.  In  the  most  severe  types  of  localized  cystitis  he  found  all  treatment 
save  excision  of  the  affected  areas  or  their  destruction  by  the  cautery  to  be 
useless. 

If  these  methods  of  treatment  do  not  relieve  the  patient  and  it  is  evident  that 
his  strength  is  rapidly  failing  from  septic  absorption,  suprapubic  or  perineal 
drainage  is  indicated.  When  the  cutting  operation  is  forced  on  the  surgeon 
in  place  of  catheterization  and  irrigations,  because  of  the  pain  and  reaction 
which  they  excite,  forcible  dilatation  of  the  prostatic  urethra  is  a  most  im- 
portant procedure,  since  this  will  always  for  a  time  and  often  permanently 
relieve  the  violent  and  exhausting  tenesmus  from  which  this  class  of  patients 
habitually  suffer. 

Syphilis   of  the   Bladder 

The  symptoms  of  syphilis  of  the  bladder  present  no  features  characteristic 
of  the  infection.  The  patient's  attention  may  be  attracted  to  the  bladder  because 
of  the  discomforts  usually  accompanying  an  ordinary  cystitis;  or  the  first  symp- 
tom may  be  a  sudden  painless  haematuria.  In  the  majority  of  cases  there  is 
painful,  frequent  micturition,  acompanied  at  times  with  terminal  haematuria  of 
various  degrees.- 

Specific  infection  of  the  bladder  is  commoner  in  the  tertiary  than  in  the 
secondary  stage  of  syphilis,  and  is  then  characterized  by  more  pronounced  dis- 
tress. Few  cases  have  been  reported,  possibly  because  many  have  escaped 
recognition. 

The  diagnosis  of  syphilitic  cystitis  must  be  based  on  the  presence  of  other 
symptoms  of  the  disease  or  a  positive  Wassermann,  and  the  absence  of  other 
adequate  cause.  A  pus-free  urine  is  suggestive  of  the  disease.  Cystoscopic 
examination  may  reveal  an  intensely  reddened  bladder,  single  or  multiple  ulcers, 
or  a  papillomatous  hyperplasia. 

The  treatment  is  that  of  the  causal  infection;  local  treatment  is  contra- 
indicated. 

^ Baker:  "Syphilis  of  the  Bladder,"  Surg.,  Gynec,  and  Obstet.,  1917,  xxiv,  187. 


SURGERY  OF  THE  BLADDER 


501 


Perivesical  Inflammation 
Two  forms  of  perivesical  inflammation  are  described  by  Halle,  the  cicatricial 
and  the  suppurative. 

Cicatricial  pericystitis  is  the  result  of  chronic  pelvic  cellulitis,  and  is 
characterized  by  accumulations  of  sclero-adipose  tissue  about  the  base  and  sides 
of  the  bladder. .  The  perivesical  tissue  becomes  dense  and  greatly  thickened,  and 
firmly  mats  the  pelvic  organs  together.  The  masses  of  this  tissue,  by  forming 
about  the  vesical  insertion  of  the  ureters,  may  produce  occlusion  of  these  canals. 

Suppurative  pericystitis  appears  in  the  form  of  abscesses,  developing  in  the 
normal  fibro-adipose  tissue  surrounding  the  bladder  (Fig.  247).  Usually  these 
abscesses  are  secondary  to  prostatitis  or  cystitis.     It  is  evident  that  they  may 


A"- 


PlG.     247. — Pericystitis.       .4,    perivesical    abscess;  B, 

greatly    thickened    external    coats    of    bladder;    incident  to 

perivesical     inflammation.        (From     Wistar     Institute  of 
Anatomy,   University  of  Pennsylvania.) 

form  in  cases  of  wounds,  or  ulceration  of  the  bladder.  The  ulceration  may  be 
tuberculous  or  malignant.  More  commonly  it  is  erosive,  and  is  caused  by  stone 
or  foreign  body.  The  abscesses  of  parenchymatous  cystitis  may  rupture  ex- 
ternally and  affect  the  perivesical  tissues;  usually  they  discharge  into  the  blad- 
der. Suppurative  pericystitis  due  to  stone  ulcerating  through  the  bladder-wall 
is  localized  and  develops  slowly.  It  may  discharge  upon  the  skin  surface, 
usually  in  the  perineum,  or  empty  into  the  rectum  or  the  peritoneal  cavity. 

Prevesical  Abscess. — There  is  one  form  of  perivesical  inflammation  which, 
from  the  fact  that  it  is  often  primary  and  if  promptly  recognized  can  be  success- 
fully treated,  requires  special  consideration;  this  is  prevesical  suppuration,  or 
abscess  in  the  space  of  Retzius. 

This  space  is  entirely  external  to  the  peritoneum,  and  serves  in  part  to 
give  the  bladder  room  to  expand  and  fill  with  urine.  It  is  bounded  anteriorly 
by  the  pubis  and  the  anterior  layer  of  the  transversalis  fascia  of  Cooper,  behind 


502  GEXITO-URIXARY  SURGERY 

by  the  posterior  layer  of  that  fascia  and  by  the  bladder.  That  part  of  the 
space  \Yhich  extends  upward  be3-ond  the  pubis  is  limited  above  by  the  line  of 
union  of  the  two  layers  of  fascia  which  are  given  off  at  the  lower  border  of  the 
sheath  of  the  recti  muscles  posteriorly,  and  has  for  its  lateral  limits  the  union 
of  these  layers  wdth  the  aponeurosis  of  the  transversalis  and  oblique  muscles. 
Below,  the  space  is  limited  by  the  prostatic  sheath  and  the  superior  aponeurosis 
of  the  true  pelvis. 

Suppuration  in  this  region  may  be  caused  by  traumatism,  operative  or  other- 
wise, or  by  infection  of  neighboring  organs,  such  as  the  bladder,  prostate,  uterus, 
etc.  Englisch,  quoted  by  Thorndike,  classes  all  cases  of  prevesical  suppuration 
under  three  headings:  (1)  those  caused  b}-  traumatism;  (2)  those  caused  by 
metastasis;  and  (3)  those  caused  by  direct  extension  from  neighboring  organs 
or  tissues. 

It  is  evident  from  the  boundaries  of  this  space  that  pus  may  open  through 
the  anterior  abdominal  wall  into  the  rectum,  the  bladder  or  urethra,  the  peri- 
neum, or  the  peritoneal  cavity.  A  certain  proportion  of  these  cases  give  a 
tuberculous  history,  but  proof  as  to  the  causative  agency  of  the  tubercle  bacillus 
is  wanting. 

Symptoms. — The  symptoms  of  prevesical  suppuration  are  vesical  tenesmus 
and  irritability,  pain,  not  sharply  localized,  often  referred  to  the  bowels  and 
associated  v\-ith  digestive  disturbances,  the  formation  of  a  tumor  occupying  the 
position  of  a  distended  bladder  and  discoverable  on  suprapubic  or  bimanual 
palpation,  local  tenderness,  and  usually  constitutional  symptoms  of  suppuration. 

Diagnosis. — The  formation  of  inflammatory  infiltration  behind  the  pubis 
associated  with  symptoms  of  vesical  irritability  would  in  the  absence  of  cystitis 
be  sufficiently  characteristic  of  prevesical  inflammation.  \Mien  cystitis  is  present 
the  persistence  of  the  tumor  after  thorough  evacuation  of  the  bladder-contents 
would  also  be  pathognomonic.  "\Mien  the  abscess  points  forward  in  the  middle 
Hne,  perhaps  the  only  condition  with  which  it  is  likely  to  be  confused  is  post- 
rectus  suppuration,  the  pus  then  lying  behind  the  rectus  muscle  and  between 
it  and  the  layer  of  fascia  w^hich  descends  directly  to  the  pubis.  In  this  case 
the  pus  would  be  limited  laterally  b}^  the  borders  of  the  recti  muscles  and 
would  extend  upward.  The  induration  of  prevesical  inflammation  extends 
laterally  beyond  the  limits  of  the  recti  muscles,  and  is  usually  symmetrically 
developed  in  the  two  sides.  Exceptionally  the  abscess  extends  towards  one  side 
only.  We  have  operated  on  one  such  case  where  because  of  associated  in- 
testinal S3Tnptoms  the  condition  was  diagnosed  as  incarcerated  hernia.  Careful 
bimanual  palpation  suggested  the  true  nature  of  the  affection,  and  the  presence 
of  pus  was  confirmed  by  an  incision. 

Prognosis. — This  is  favorable,  especialh''  w^hen  the  condition  is  properly 
diagnosed  and  treated  by  earh^  evacuation  of  the  pus.  Of  Englisch's  thirty- 
three  reported  cases  four  died  from  a  general  purulent  peritonitis  folloAving 
perforation  of  the  abscess  into  the  peritoneal  cavity. 

Treatment. — Suppuration  requires  evacuation  and  drainage.  In  the  absence 
of  pointing,  incision  should  be  made  in  the  middle  line  directly  over  the  pubis. 
Drainage  should  be  secured  by  gauze  packing.  The  same  rule  applies  to  all 
perivesical  suppuration. 

In  the  treatment  of  that  form  of  chronic  perivesical  inflammation  which  is 


SURGERY  OF  THE  BLADDER  503 

characterized  by  the  formation  of  masses  of  fibro-lipomatous  tissue  attention 
should  first  be  directed  to  the  cure  of  the  condition  which  has  produced  or  is 
keeping  up  pelvic  cellulitis.  This  may  be  an  untreated  cystitis,  with  diverticula, 
or,  in  the  case  of  women,  endometritis  and  perimetritis.  Hot  rectal  douches 
of  normal  saline  solution  and  massage  through  the  rectum  and  over  the  pubis 
may  be  serviceable. 

TUBERCULOSIS  OF  THE  BLADDER 

Tuberculosis  of  the  bladder  is  a  disease  of  early  and  middle  life,  occurring 
chiefly  between  the  ages  of  fifteen  and  forty;  it  has  been  observed,  however, 
in  children  four  or  five  years  old,  and  Tapret  noted  a  case  occurring  in  a  man 
at  the  extreme  age  of  ninety-seven.  It  is  found  more  frequently  in  males  than 
in  females,  and  is  usually  associated  with  tuberculosis  of  the  kidneys,  often 
with  that  of  the  seminal  vesicles,  epididymes,  and  prostate. 

Etiology. — The  predisposing  causes  have  been  found  to  be  tuberculous 
nephritis,  a  general  tuberculous  tendency,  often  inherited,  together  with  an 
infectious  cystitis. 

The  exciting  cause  is  infection  with  the  tubercle  bacilli.  Primary  tuberculosis 
of  the  urinary  organs  is  most  Hkely  to  attack  the  kidneys.  Tuberculosis  of  the 
bladder  is  usually  a  descending  one  from  the  kidney;  occasionally  it  is  secondary 
to  tuberculous  epididymitis  or  vesiculitis. 

Pathological  Anatomy. — In  well-marked  cases  of  tuberculous  inflamma- 
tion of  the  bladder  there  is  a  pericystitis,  characterized  by  yellow,  fibrolipo- 
matous infiltration  and  degeneration;  the  bladder- walls  are  thickened  and 
rugous.  The  mucous  membrane  is  ecchymotic  in  spots,  and  may  be  studded 
with  miliary  tubercles.  Granulations  can  rarely  be  seen,  but  when  visible  they 
appear  as  fine  gray  dots,  sometimes  confluent,  forming  granulomata  of  con- 
siderable size.  Ulcerations,  either  single  or  multiple,  are  found  in  the  mucous 
membrane.  Their  edges  are  irregularly  excavated,  their  base  a  greenish  gray 
covered  with  thick  pus.  In  depth  they  are  very  variable,  sometimes  only 
invading  the  mucous  membrane,  again  even  perforating  the  bladder-walls  and 
producing  perivesical  abscesses,  or  fistulae  opening  into  the  rectum,  vagina,  or 
hypogastrium ;  fistulae,  however,  are  rare.  Microscopically,  it  is  seen  that  the 
tuberculous  granulations  arise  in  the  superficial  layers  of  the  miucous  membrane, 
and  in  these  lesions,  which  are  commonly  in  or  near  the  trigonum,  the  tubercle 
bacillus  and  many  septic  bacteria  will  be  found. 

Symptoms. — Vesical  tuberculosis  may  develop  so  insidiously  that  its  presence 
is  not  suspected  till  a  urinary  examination,  made  in  the  course  of  an  examination 
for  life  insurance,  for  instance,  shows  the  pus  or  blood.  In  these  cases  there 
have  been  no  symptoms,  or  perhaps,  when  questioned,  the  patient  will  remember 
that  he  has  been  slightly  troubled  by  a  somewhat  frequent  urination,  chiefly 
after  meals  and  during  the  night.  The  urine  is  clear  and  limpid,  is  passed  every 
hour  or  so,  and  the  frequency,  which  in  children  may  cause  nocturnal  incon- 
tinence, is  aggravated  by  the  dorsal  decubitus. 

Haematuria  in  many  cases  is  an  early  symptom.  The  bleeding  is  slight, 
spontaneous,  and  sometimes  terminal,  a  few  drops  of  pure  blood  following  the 
claret-colored  urine.    It  often  stops  as  suddenly  and  inexplicably  as  it  begins. 


504  GENITO-URINARY  SURGERY 

and  may  not  reappear  for  days  or  weeks.  This  symptom  becomes  gradually 
less  prominent  as  the  disease  progresses.  Exceptionally  there  may  be  a  profuse 
hemorrhage,  but  this  is  less  common  than  in  the  presence  of  vesical  tumor. 

Pain,  when  pronounced,  usually  denotes  the  onset  of  a  mixed  infection,  to 
which  the  tuberculous  bladder  is  almost  inevitably  doomed.  The  usual  cause 
of  cystitis  is  catheterization,  but  it  develops  spontaneously  in  the  absence  of 
instrumentation.  Cystitis  having  been  inaugurated,  pain  becomes  one  of  the 
most  constant,  prominent,  and  harassing  symptoms  of  the  disease.  The  patient 
is  tortured  day  and  night  by  urgent  desire  to  urinate  and  by  violent  tenesmus, 
sometimes  recurring  every  few  minutes;  and  the  pain  may  be  felt  at  all  stages 
of  urination.  These  symptoms  are  most  pronounced  when  the  tuberculous 
process  attacks  the  region  of  the  trigonum;  when  the  lesions  involve  other  parts 
of  the  bladder  it  may  happen  that  an  advanced  stage  of  vesical  tuberculosis 
will  be  reached  before  pain  manifests  itself. 

Retention  of  urine  occasionally  results  from  spasm  and  inflammatory  ob- 
struction of  the  internal  urethral  orifice,  and  again  true  incontinence  may  arise 
from  destruction  of  the  neck  of  the  bladder  by  the  tuberculous  process. 

Pus  is  usually  present,  and  if  containing  greatly  deformed  leucocytes  and 
no  microorganisms  is  strongly  suggestive  of  tuberculosis.  Before  mixed  infec- 
tion the  urine  is  limpid  or  at  most  fairly  tinged  with  blood. 

The  method  of  staining  the  tubercle  bacillus  has  been  given  (see  p.  19) .  The 
best  way  of  establishing  its  presence  is  by  inoculation  of  the  lower  animals. 
Many  examinations  and  efforts  at  culture  are  often  required  before  the  bacillus 
is  found. 

In  the  female  a  painful  zone  of  ulcerations  may  sometimes  be  seen  at  the 
meatus  urinarius,  extending  thence  up  the  urethra. 

The  general  health  suffers  as  is  the  case  in  tuberculosis  of  other  organs. 
There  is  loss  of  flesh  and  strength  and,  if  mixed  infection  is  present,  there  is 
also  chronic  septicaemia  accompanied  by  fever,  night-sweats,  loss  of  appetite 
and  often  by  diarrhoea.  In  such  cases  the  pain  is  an  important  factor  in  pro- 
ducing deterioration  of  the  general  health. 

Diagnosis. — Probably  in  a  large  majority  of  cases  tuberculous  cystitis  is 
not  suspected  till  the  disease  is  well  advanced  and  has  spread  wide  of  the 
bladder. 

Koning  states  that  half  the  patients  who  complain  of  pus  and  mucus  in  the 
urine  as  the  principal  symptom  are  tuberculous;  it  is  certainly  the  case  that 
tuberculous  cystitis  is  by  no  means  a  rare  disease. 

There  is  no  pathognomonic  sign  or  symptom  of  tuberculous  cystitis  except 
discovery  of  the  bacillus  in  the  urine  from  an  inflamed  bladder,  and  sometimes 
the  cystoscopic  appearance.  Tuberculosis  should,  however,  be  suspected  when 
(1)  there  is  a  characteristic  family  history;  (2)  there  have  been  frequent  urina- 
tion and  haematuria  without  discoverable  cause;  (3)  cystitis  develops  and 
persists  in  the  absence  of  the  ordinary  predisposing  and  exciting  causes;  (4) 
the  epididymis,  cord,  prostate,  or  seminal  vesicles  show  signs  of  tuberculous 
involvement;  (5)  there  are  signs  and  symptoms  of  tuberculosis  in  other  parts 
of  the  body;  (6)  tuberculosis  is  apparently  the  only  cause  which  can  satisfac- 
torilv  account  for  symptoms. 

The  cystoscopic  appearances  indicative  of  vesical   tuberculosis  are:     dis- 


SURGERY  OF  THE  BLADDER  505 

seminated  or  grouped  tubercles;  ragged,  irregular,  punched-out  necrotic  ulcers; 
and  acutely,  subacutely,  or  chronically  inflamed  areolae  surrounding  tunnel- 
shaped  or  sewer-like  ureteral  orifices.  It  may  happen  that  the  appearances  are 
not  typical,  as  when  the  infiltrated  rugae  simulate  neoplasm,  due  to  the  forma- 
tion of  granulomata. 

Prognosis. — This  is  good  when  other  foci  of  the  disease  can  be  removed; 
otherwise  the  condition  is  practically  hopeless.  With  the  removal  of  the  pri- 
mary focus,  as  a  tuberculous  kidney,  the  bladder  commonly  proceeds  to  spon- 
taneous cure ;  when  this  does  not  occur  persistent  treatment  usually  brings  about 
the  desired  result.  When  the  primary  focus  cannot  be  eradicated,  either  by 
surgical  or  other  therapeutic  measures,  treatment  directed  to  the  bladder  infec- 
tion is  to  be  regarded  as  merely  a  palliative  procedure.  Under  these  circum- 
stances the  bladder  inflammation  and  symptoms  usually  become  progressively 
worse,  till  death  from  the  original  focus  of  disease  or  from  some  intercurrent 
condition  comes  as  a  welcome  relief  from  suffering. 

Treatment. — Since  vesical  tuberculosis  is  nearly  always  secondary,  the 
first  thought  in  treatment  should  be  to  discover  the  source  of  the  disease; 
and,  as  this  is  in  one  or  both  kidneys  in  a  very  large  percentage  of  cases,  a 
renal  origin  is  always  to  be  suspected.  When  nephrectomy  is  a  permissible 
operation,  it  is  our  most  potent  means  in  the  treatment  of  vesical  tuberculosis. 

When  the  primary  focus  cannot  be  removed  for  any  reason,  and  when  the 
vesical  condition  fails  to  mend  with  the  desired  celerity  after  such  removal, 
certain  measures  are  applicable  with  the  idea  of  ameliorating  the  symptoms 
or  hastening  the  "cure  of  the  condition.  In  the  performance  of  all  manipulations 
wherein  the  bladder  is  entered  by  instruments,  the  greatest  care  must  be  exer- 
cised to  prevent  the  infection  of  the  bladder  with  additional  organisms. 

It  is  important  to  get  the  patient  in  the  best  possible  condition,  to  make 
use  of  the  beneficial  effects  of  sunlight  and  fresh  air,  and  usually  to  employ 
tuberculin  therapy  for  the  purpose  of  increasing  the  individual's  specific  re- 
sistance to  the  tubercle  bacillus. 

Local  treatment  of  the  bladder  must  be  conducted  with  extreme  caution. 
Irrigations  are  not  well  borne  as  a  rule,  and  should  rarely  be  employed.  Par- 
ticularly is  silver  nitrate  contra-indicated  in  tuberculous  disease  of  the  bladder. 

The  best  results  are  obtained  by  posterior  urethral  instillations  of  bichloride 
of  mercury  and  of  phenol.  The  former  of  these  is  used  in  dilutions  of  from 
1:  20,000  to  1:  500,  while  the  latter  is  applicable  in  strengths  of  1:  200  to 
1:  20.  From  five  to  twenty  minims  may  be  instifled.  The  strength  of  the 
solution  should  be  such  that  the  pain  produced  is  of  an  easily  bearable  degree, 
and  is  proportionately  less  than  the  relief  obtained  as  a  result  of  the  treatment; 
the  stronger  solutions  mentioned  should  be  used  only  after  a  long  gradual 
approach. 

Other  substances  which  may  be  used  are  iodoform  emulsion  (10  per  cent, 
in  oil),  gomenol  oil  (25  per  cent,  in  oil),  and  thallin  sulphate  (3  to  20  per 
cent.). 

The  frequency  of  the  application  of  any  of  these  substances  should  be  such 
that  all  reaction  from  one  treatment  shall  have  disappeared  before  the  next  is 
administered;  the  usual  interval  is  two,  three,  or  four  days. 

WTien  the  pain  in  the  bladder  is  severe,  resort  must  be  had  to  anodynes. 


506  GENlTO-URINARY  SURGERY 

A  favorite  way  of  administering  these  is  by  the  rectum,  either  by  suppositories 
(extract  opii  gr.  y^  to  i,  combined  with  ext.  bellad.  gr.  34?  or  ext.  hyoscyami 
gr.  }4  to  i),  or  by  means  of  a  syringe  fifteen  to  thirty  grains  of  antipyrine  and 
ten  to  twenty  minims  of  laudanum  dissolved  in  one-half  ounce  of  water  may 
be  injected. 

Operati6n  is  indicated  when  the  pain  and  urgency  become  unbearable  and 
are  not  controllable  by  safe  doses  of  narcotics.  Under  these  circumstances 
there  will  often  be  infiltration  of  the  prostate  and  seminal  vesicles:  hence  com- 
plete eradication  of  the  disease  will  be  no  longer  practicable.  The  operation 
is  then  performed  as  a  measure  of  relief  and  not  as  one  of  cure,  the  bladder 
being  drained  through  either  a  perineal  or  a  suprapubic  opening.  Often  this 
drainage  gives  immediate  and  complete  relief.  Sometimes  pain  and  tenesmus 
persist.  The  suprapubic  cystotomy  is  to  be  preferred,  since  the  bladder  is  more 
liable  to  be  opened  at  a  point  somewhat  removed  from  the  most  active  region 
of  the  tuberculous  process.  A  perineal  wound  is  very  apt  to  become  infected, 
whereby  troublesome  fistulas  are  formed. 

The  suprapubic  operation  also  possesses  the  advantage  of  allowing  the  sur- 
geon to  inspect  the  interior  of  the  bladder  and  to  treat  directly  intravesical 
lesions.  These  may  be  thoroughly  curetted  and  well  rubbed  with  iodoform,  or 
may  be  destroyed  by  the  application  of  the  actual  cautery  or  the  high  frequency 
current.  Following  these  procedures  there  are  some  reported  cures.  Were 
tuberculosis  more  often  confined  to  the  bladder,  this  form  of  intervention 
would  promise  brilliant  results. 

Having  opened  and  drained  the  bladder  above  the  pubis  and  destroyed  or 
removed  tuberculous  ulcers,  the  vesical  mucosa  is  kept  as  clean  as  possible  by 
irrigations  with  normal  salt  solution  or  a  weak  antiseptic,  provided  it  does  not 
excite  too  much  reaction.  Sometimes  as  a  result  of  this  treatment  cystitis  is 
cured  and  the  tuberculous  process  appears  to  be  checked,  the  suprapubic  opening 
closing  on  removal  of  the  drainage-tube.  There  is,  however,  a  constant  risk 
that  the  abdominal  wound  may  reopen  and  an  abdominal  hernia  be  the  outcome. 
In  unfavorable  cases  the  tract  of  the  drainage-tube  often  becomes  tuberculous. 


CHAPTER  XXIII 

SURGERY  OF  THE  BLADDER  (Continued) 

CALCULI  AND  FOREIGN  BODIES 
CALCULUS 

A  VESICAL  CALCULUS  is  E  coHcretion  of  the  solid  urinary  constituents  lying 
in  the  bladder.  It  becomes  a  surgical  problem  when  it  is  of  such  size  or  so 
placed  that  it  does  not  escape  through  the  normal  passages.  Calcuh  may  be 
formed  in  the  bladder,  or  may  have  their  origin  in  the  kidneys. 

Calculi  may  be  generally  grouped  under  the  following  headings: 

1.  Those  formed  from  the  normal  constituents  of  the  urine, — the  uric  acid, 
the  phosphatic,  the  mixed,  and  the  urate  calculi. 

2.  Calculi  formed  of  salts  found  in  normal  urine,  but  never  present  in  excess 
except  in  disease, — the  oxalates  and  carbonates. 

3.  Concretions  formed  from  elements  entirely  foreign  to  normal  urine, — 
cystin,  indigo,  and  xanthic  oxide. 

The  large  majority  of  stones  are  formed  of  uric  acid  and  the  urates;  the 
phosphatic  and  mixed  calculi  come  next  in  order  of  frequency;  and  last  come 
the   oxalates   and   rarer   forms, — indigo,   xanthic   oxide,   etc. 

Uric  acid  calculi  (Fig.  248,  A),  formed  in  the. kidney  pelvis,  descend  through 
the  ureter  to  the  bladder,  usually  causing  that  form  of  violent  and  paroxysmal 
pain  which  is  termed  renal  colic.  Once  in  the  bladder  their  further  growth  is 
due  to  accretion  of  uric  acid  alone,  or  they  may  form  nuclei  for  the  deposition 
of  other  elements.  (Fig.  248,  E.)  Uric  acid  calculi  are  generally  smooth, 
spheroidal,  moderately  hard,  and  yellow  to  reddish  brown  in  color. 

High  living  and  a  gouty  diathesis  are  factors  predisposing  to  the  formation 
of  these  concretions.    They  occur  at  the  extremes  of  life. 

Urate  Calculi. — Sodium,  potassium,  and  ammonium  urates,  though  rarely 
forming  large  stones,  are  constantly  and  copiously  deposited  as  sediment  in 
febrile  affections,  and  when  from  any  cause  the  urine  becomes  markedly  con- 
centrated. Urate  calculi  are  observed  almost  exclusively  in  children.  In  the 
adult  they  may  form  the  nuclei  of  large  concretions  made  up  of  divers  ele- 
ments.   They  are  grayish  yellow  in  color.     (Fig.  248,  H.) 

Phosphatic  calculi  follow  the  uric  acid  and  urate  concretions  in  order  of 
frequency;  there  are  three  varieties. 

1.  The  amorphous  calcium  phosphate  rarely  forms  a  calculus  of  itself.  It 
is  commonly  deposited  in  layers  about  calculi  of  other  salts,  or  is  intermingled 
with  them,  sometimes  reaching  considerable  size.  It  crumbles  easily;  its  color 
is  a  dirty  brown  or  white  (Fig.  248,  B). 

,  2.  The  triple  phosphates  (ammonio-magnesium  phosphates)  are  'commoner 
in  calculus  formation  than  calcium  phosphate.  Such  calculi  are  crystalline  and 
of  a  whitish  color.  Formed  in  ammoniacal  urine  only,  they  are  vesical  in 
origin  and  frequently  complicate  cystitis. 

507 


508 


GENITO-URINARY  SURGERY 


F 


H 


Fig.  248. — Vesical  calculi.  A,  uric  acid;  B,  phosphate;  C  and  F, 
oxalate  stone  with  phosphatic  incrustations;  D,  cystin;  E,  uric  acid  with  phos- 
phatic  incrustation;  G,  mixed  stone,  chiefly  uric  acid  and  phosphates;  H,  urate. 


SURGERY  OF  THE  BLADDER  509 

3.  Mixed  fusible  calculi,  being  composed  of  the  triple  phosphates  and 
calcium  phosphate,  are  not  uniform  throughout;  they  form  about  a  nucleus  of 
calcium  oxalate,  uric  acid,  foreign  bodies,  etc.  (Fig.  24S,  G).  They  appear  as 
masses  which  resemble  white  friable  mortar,  and  are  formed  in  ammoniacal  urine. 
Calcium  oxalate  calculi^  like  those  of  uric  acid,  are  of  renal  origin,  and 
occur  most  frequently  in  patients  suffering  from  oxaluria,  a  diathesis  associated 
with  indigestion  and  neurasthenia.  These  are  the  hardest  of  all  stones,  and 
are  usually  small  or  of  medium  size,  spheroidal  in  shape,  dark  brown  or  black 
in  color,  and  have  a  tuberculated  surface,  giving  rise  to  the  name  of  mulberry 
calculus  (Fig.  249).  Amorphous  urates  and  phosphates  are  often  deposited 
between  the  tuberculations  (Fig.  248,  C),  or  may  entirely  encase  the  oxalate 
(Fig.  248,  F). 

Calcium  carbonate  calculi  are  rare.  When  found  they  have  been  multiple, 
small,  weighing  from  thirty  to  forty  grains  each,  and  hard  and  lamellar  in  struc- 
ture, similar  to  the  calcium  oxalate  calculi. 

Cystin  Calculi. — Cystin  as  a  major  constituent  of  calculus  is  extremely 
rare.     As  is  the  case  with  the  uric  acid  and  calcium  oxalate  calculi,  cystin 

concretions  originate  in  the  kidney.  In  appearance 
they  are  irregular  and  knotty,  sections  showing  no 
attempt  at  crystallization,  waxy  and  yellowish  white 
at  first,  but  turning  to  green  after  long  exposure  to 
the  air  (Fig.  248,  D). 

Xanthin  is  another  rare  constituent  of   calculus. 
Indigo  does  not  form  a  calculus  in  itself,  but  may  be 
so  important  an  ingredient  that  it  gives  the  stone  its 
typical  color.    It  occurs  in  cases  of  liver  disease  asso- 
_g^  ciated  with  cystitis. 

Fig.  249.-Muiberry  calculus.         ^  calculus  is  named  from  its  preponderating  ele- 
(From    the  German  Hospital,   mcnt,  but  usually  there  is  fouud  oue  Salt  serving  as  a 

Philadelphia.)  '  •    ,       n  ,•       l-rr  -,  •  n 

nucleus,  with  layers  of  different  salts  superimposed. 
Thus,  the  phosphatic  calculus  is  often  found  to  have  in  its  centre  a  minute 
concretion  of  calcium  oxalate  or  uric  acid.  On  dissolving  out  the  salts  of 
even  the  smallest  calculus  there  will  be  found  an  albuminoid  or  colloid  frame- 
work upon  which  these  have  crystallized,  and  which  serves  to  agglutinate 
the  mass.  Rainey  and  Ord  have  demonstrated  the  tendency  of  crystalline  salts 
when  in  solution  with  colloid  or  albuminoid  substances  to  assume  rounded  or 
spheroidal  forms  in  crystallization.  It  is  certain  that  the  development  of  stone 
is  not  wholly  due  to  the  mere  presence  of  an  excess  of  any  of  the  urinary  salts, 
for  copious  deposits  of  uric  acid  and  the  phosphates  may  exist  for  years  without 
any  evidence  of  calculus  formation. 

If,  however,  at  a  time  when  the  urinary  salts  are  in  excess,  any  renal  or 
vesical  irritation  is  lighted  up,  by  means  of  which  blood  and  serum  are  inter- 
mingled with  the  urine,  furnishing  an  albuminoid  substance  which  favors  the 
agglutination  of  the  small  crystals,  calculi  may  form,  and,  once  formed,  tend 
to  increase  in  size. 

Vesical  calculi,  when  free,  are  usually  spheroidal.  They  may  be  irregular 
or  faceted  from  multiplicity  and  erosion,  or  from  having  been  moulded  in  a 


510  genito-urinaRy  surgery 

diverticulum  or  in  the  prostatic  urethra.  Ord  holds  that  calculi  split  sponta- 
neously because,  incident  to  changes  in  the  specific  gravity  of  the  urine,  the 
colloid  framework  becomes  swollen  by  absorption  of  a  liquid  of  different  den- 
sity, and  the  concretions  fracture  along  the  lines  of  deposition  upon  this  frame- 
work. 

Etiology. — It  is  evident  that  for  calculi  to  form  two  main  factors  are 
requisite:  first,  a  diathetic  tendency  to  over-elimination  of  the  urinary  solids 
which  form  the  basis  of  calculi;  and,  second,  local  conditions  which  cause  these 
solids  to  conglomerate. 

The  diathetic  tendency  is  strongly  marked  in  certain  localities,  but  these 
are  so  widespread,  so  totally  different  in  climate  and  surroundings,  and  the  diet 
and  habits  of  the  people  so  differ,  that  no  general  law  can  be  deduced  which 
bears  on  calculus  formation. 

There  is  a  popular  belief  that  a  limestone  soil  which  furnishes  hard  drink- 
ing-water predispQses  to  calculus;  but,  although  the  disease  is  quite  common 
in  many  limestone  districts,  it  is  equally  common  in  sandstone  districts;  more- 
over, there  is  no  reason  why  the  ingestion  of  lime  should  cause  uric  acid  de- 
posits. Vesical  calculi  are  found  in  cold  as  well  as  in  warm  countries;  for 
instance,  in  Southern  China  and  in  Northern  Scotland.  They  are  more  frequent 
in  the  central  United  States  than  in  New  England  and  the  Southern  States, 
and  one  section  of  a  single  State  may  furnish  more  cases  than  another. 

Urinary  calculi  are  found  from  extreme  youth,  even  in  the  foetal  bladder, 
to  old  age. 

In  the  statistics  of  Civiale,  Coulson,  and  Thompson,  compiled  from  10,467 
cases,  62.33  per  cent,  occurred  in  persons  under  twenty  years  of  age;  these 
cases  were  taken  from  hospital  patients  representing  the  poorer  classes.  Sir 
Henry  Thompson,  in  a  series  of  private  cases  numbering  798,  operated  for 
vesical  calculus  93  times  in  patients  between  the  ages  of  sixteen  and  fifty  years; 
527  times  in  patients  ranging  between  fifty  and  seventy;  175  times  in  patients 
over  seventy;  and  but  3  times  in  patients  under  sixteen. 

He  believes  that  calculi  are  so  frequently  found  in  hospital  and  charity 
practice  in  patients  under  twenty  years  of  age  because  of  the  bad  hygienic  sur- 
roundings, irregular  diet,  and  malnutrition  of  children  in  the  lower  walks  of  life. 
He  accounts  for  more  than  sixty-six  per  cent,  of  his  private  calculus  patients 
being  over  fifty  years  of  age  on  the  ground  that  the  upper  and  middle  classes 
of  society  are  predisposed  to  the  uric  acid  diathesis  after  the  age  of  fift}^,  because 
then  vital  activity  diminishes,  and  the  desire  for  rest  and  a  sedentary  life  are 
indulged,  without  commensurate  lessening  of  the  quantity  and  quality  of 
food  ingested.  It  would  therefore  seem  that  insufficient  clothing,  lack  of  proper 
nourishment,  and  improper  hygienic  surroundings  among  children  predispose 
to  calculus  formation,  while  among  adults  the  same  effect  is  produced  by  con- 
ditions of  a  very  different  character. 

The  relative  difference  in  the  length  and  dilatability  of  the  male  and  the 
female  urethra  probably  explains  the  greater  frequenc}^  of  calculus  in  men.  A 
small  uric  acid  stone  reaching  the  female  bladder  has  little  tendency  to  linger 
there,  the  short,  wide  urethra  allowing  it  to  pass  \^athout  producing  even  a 
sensation  of  uneasiness.     The  vesical  calculi  observed  in  women  are  usually 


SURGERY  OF  THE  BLADDER  511 

incrustations  about  a  foreign  body.  The  proportion  of  calculi  found  in  the 
female  bladder  as  compared  to  the  male  bladder  is  about  one  to  twenty- two. 

Symptoms. — Preceding  the  formation  of  a  stone  there  may  be  a  history  of 
gravel,  of  oxaluria,  of  heavy  deposits  of  urates.  When  the  stone  is  of  uric  acid 
and  is  formed  in  the  kidney,  lumbar  pains,  haematuria,  and  renal  coHc  often 
precede  its  arrival  in  the  bladder;  it  may,  however,  reach  this  viscus  without 
exciting  the  slightest  symptom. 

Having  reached  the  bladder,  the  stone  acts  as  a  sterile  foreign  body,  pro- 
ducing irritation  and  congestion,  and  thus  favoring  the  development  of  cystitis. 
Frequent  micturition,  pain,  haematuria,  and  reflex  disturbances  are  the  promi- 
nent symptoms. 

Frequent  Urination. — This  symptom  is  most  marked  in  the  day-time:  it 
is  aggravated  by  motion,  and  relieved  by  rest.  The  desire  to  urinate  comes  sud- 
denly and  is  almost  irresistible.  The  patient  may  be  compelled  to  urinate  every 
two  or  three  hours,  or  in  some  cases  every  few  minutes.  The  act  of  urination 
is  often  accompanied  by  much  tenesmus,  in  which  the  rectum  participates,  so 
that  prolapse  of  the  bowel,  particularly  in  children,  is  by  no  means  uncommon. 
A  small  stone  irregular  in  shape  produces  a  more  aggravated  condition  of 
frequent  urination  than  a  large,  smooth  calculus.  An  encysted  or  adherent 
stone,  or  one  which  lies  at  the  base  of  a  bladder  so  changed  in  shape  that  the 
calculus  is  not  liable  to  come  in  contact  with  the  vesical  neck,  often  gives  rise 
to  no  marked  frequency  of  urination.  It  is  to  be  noted  that  frequent  urination 
is  a  symptom  of  so  many  other  bladder  conditions  that  in  itself  it  does  not 
necessarily  suggest  the  presence  of  stone. 

Exceptionally  there  is  sudden  stoppage  during  the  passage  of  a  full-sized 
stream.  This  is  observed  chiefly  in  young  persons  and  in  patients  having  small 
stones,  since  it  is  due  to  the  dropping  forward  of  the  calculus  into  the  vesical 
orifice  of  the  urethra.  It  is  extremely  suggestive  of  calculus  if  it  can  be  obviated 
by  the  patient  urinating  in  certain  positions,  as,  for  instance,  when  lying  on 
the  back.  As  with  frequent  micturition,  sudden  interruption  of  the  stream  is 
a  symptom  of  inflammatory  troubles  of  the  vesical  neck,  and  is  not  pathogno- 
monic of  stone. 

Pain. — The  pain  of  vesical  calculus  is  usually  referred  to  the  lower  urethral 
surface,  about  an  inch  posterior  to  the  glans.  It  is  burning  and  stinging  in 
character,  and  is  less  pronounced  in  old  men  than  in  children,  prostatic  enlarge- 
ment in  the  former  preventing  the  calculus  from  coming  in  contact  with  the 
vesical  neck. 

Pain  is  most  marked  at  the  end  of  urination,  because  then  the  inflamed 
mucous  membrane  is  brought  in  direct  contact  with  the  stone.  The  intensity 
of  pain  varies  proportionately  to  the  degree  of  cystitis  and  the  size  and  nature 
of  the  stone,  and  is  intensified  by  jarring  motions  and  by  change  in  position. 
Small  stones,  especially  if  they  be  rough,  cause  more  suffering  than  do  large 
ones.  A  history  of  pain  pronounced  during  the  early  stages  of  stone,  and 
gradually  lessening,  suggests  that  a  small  rough  stone  has  become  covered  with 
mucus  or  with  phosphatic  deposits,  thus  forming  a  smooth  surface.  A  stone 
may  be  carried  for  years  without  exciting  the  slightest  pain. 


512 


GENITO-URINARY  SURGERY 


Haematuria  is  of  importance  only  when  associated  with  other  symptoms. 
It  is  caused  by  the  mechanical  friction  and  scratching  of  the  calculus,  and  is 
most  pronounced  when  the  bladder  is  congested,  as  in  cystitis.  It  is  markedly 
aggravated  by  motion.  The  blood  is  most  apt  to  be  voided  towards  the  close 
of  urination. 

Reflex  Disturbances. — Priapism  has  been  noted  as  a  reflex,  particularly 
in  children;  in  them  it  may  lead  to  the  practice  of  masturbation,  since  pain  is 
referred  to  the  end  of  the  penis,  and  there  is  commonly  pulling  and  handling 
of  that  organ  in  instinctive  efforts  to  obtain  relief.  Reflex  pains  felt  in  the 
rectum,  the  perineum,  the  hypogastric  region,  the  small  of  the  back,  on  the 
outer  surface  of  the  thighs,  the  lower  leg,  or  the  foot,  are  frequently  noted. 


Fig.  250. — Stone-searcher, 


There  is  a  peculiar  pain  in  the  foot,  known  as  podalgia,  which  is  sometimes 
symptomatic  of  stone;  it  is  frequently  located  in  the  neighborhood  of  the  ball 
of  the  great  toe,  but  may  extend  over  the  whole  sole.  It  is  most  commonly 
observed  in  the  gouty  and  rheumatic.  It  disappears  as  soon  as  the  calculus 
is  removed.    Pain  may  also  be  felt  in  the  upper  extremities  of  the  lungs. 

Rectal  prolapse,  hemorrhoids,  and  subconjunctival  hemorrhage,  though  not 
absolute  in  their  significance,  may  aid  in  diagnosis,  since  they  are  symptomatic 
of  the  violent  straining  efforts  which  frequently  accompany  the  act  of  urination. 

True  inflammation  of  the  bladder  is  likely  to  occur  sooner  or  later,  though 
some  cases  of  stone  may  last  indefinitely  without  this  complication.  It  is 
usually  caused  by  instrumentation;  but  the  intervention  of  this  agency  is  not 
necessary  for  its  development.  It  aggravates  the  symptoms  already  given,  and 
causes  a  heavy  deposit  of  mucopus  in  the  urine. 

Diagnosis. — The  diagnosis  of  stone  is  founded  upon  physical  examination. 


Fig.  251. — Thompson's  stone-searcher. 


The  symptoms  above  described,  either  singly  or  altogether,  may  be  excited  by 
any  inflammation  or  irritation  at  the  neck  of  the  bladder  independent  of  its 
cause.  Pain  referred  to  the  under  surface  of  the  glans  penis  and  felt  most 
acutely  at  the  end  of  urination,  sudden  interruption  of  the  full  stream,  relieved 
by  change  of  posture  and  not  occurring  when  certain  postures  are  assumed,  and 
haematuria,  can  be  considered  only  as  strongly  suggestive  of  stone  and  as  calling 
for  direct  examination. 

A  vesical  calculus  may  excite  no  symptoms.  Morris  records  the  case  of  a 
man  who,  at  the  age  of  sixty-six,  learned  through  an  attack  of  haematuria 
that  he  had  vesical  calculus.  This  patient  died,  after  thirteen  years,  of  car- 
buncle of  the  neck.  He  never  again  had  a  bladder-symptom,  although  he  never 
submitted  to  operation. 


SURGERY  OF  THE  BLADDER 


513 


The  examination  is  conducted  (1)  by  bimanual  palpation;  (2)  by  ra- 
diography; (3)  by  cystoscopy,  or,  if  this  be  unavailable,  by  means  of  a  stone- 
searcher  or  sound,  or  an  evacuator  attached  to  an  aspirator. 

1.  Bimanual  palpation  is  thus  practised  in  the  male:  the  patient  having 
passed  his  water  is  directed  to  lean  well  forward  over  a  chair,  with  the  legs 
moderately  separated  and  the  abdominal  muscles  relaxed.  The  surgeon  then 
introduces  the  forefinger  of  the  right  hand  into  the  rectum  and  with  the  fingers 
of  the  left  hand  presses  upward  and  backward,  directly  over  the  pubis,  towards 
the  base  of  the  bladder.  In  place  of  standing,  the  patient  may  lie  on  his  back, 
the  head  and  shoulders  elevated,  the  thighs  flexed;  the  hands  of  the  surgeon 


Fig.  252. — Large  vesical  calculus.     (Skiagraph  made  by  Dr.  H.  K.  Pancoast.J 


are  used  as  just  described.  In  thin  subjects  and  in  those  with  not  too  muscular 
abdominal  walls,  the  presence  or  absence  of  calculus  of  even  small  size  can  some- 
times be  thus  determined. 

In  the  fem.ale  examination  is  made  through  the  vagina,  the  bladder  being 
palpated  by  the  ordinary  bimanual  manipulation. 

2.  X-ray  examination,  when  available,  represents  the  least  traumatizing 
method  of  establishing  the  diagnosis,  and  is  usually  certain  in  its  findings 
(Figs.   252   and  253). 

3.  Instrumental  exploration  is  inaugurated  by  passing  a  cystoscope.  When 
the  conditions  are  favorable  for  the  use  of  this  instrument,  this  implying  an 
experienced   operator,   further   diagnostic   examination   is   not   needed.      When 


514 


GENITO-URINARY  SURGERY 


a  cystoscopist  is  not  available,  or  bladder  conditions  negative  the  use  of  the 
instrument,  the  stone-searcher  is  serviceable.  This  instrument  should  have  a 
straight  shaft  fully  ten  inches  long,  and  a  short  curve  near  the  tip.  Two 
instruments  should  be  provided,  one  with  a  very  slight  curve,  the  other  with 
an  abrupt  curve,  permitting  it  to  be  carried  into  the  pouch  behind  the  prostate. 
The  calibre  should  be  about  13  F.  (Fig.  250).  It  is  desirable  to  begin  the 
examination  with  the  bladder  fully  distended,  and  to  allow  the  urine  gradually 
to  escape  as  the  search  is  continued.  For  this  reason,  and  because  it  allows 
of  an  approximate  estimation  of  the  size  of  the  stone,  Thompson's  stone- 


FiG.  253. — Calculi  of  bladder  and  ureter.  Skiagraphy  demonstrated  appa- 
rently two  vesical  calculi.  Cystoscope  showed  that  the  smaller  one  only  was  intra- 
vesical, the  larger  stone  lying  in  the  pelvic  end  of  the  ureter.  (Skiagram  by  Dr. 
H.  K.  Pancoast.) 

searcher  is  particularly  serviceable  (Fig.  251).  The  solid  steel  sounds  shaped  as 
already  described,  and  provided  with  flat  handles,  are  the  instruments  of  choice. 
These  sounds  are  passed  with  the  patient  in  a  recumbent  or  semi-recumbent 
position,  with  shoulders  raised  and  thighs  flexed  and  separated.  Should  cystitis 
not  be  present  it  is  particularly  important  to  conduct  all  manipulations  in 
accordance  with  the  rules  already  laid  down  for  aseptic  instrumentation  of  the 
urethra  and  the  bladder,  since  it  is  now  universally  recognized  that  the  passage 
of  instruments  is  the  usual  cause  of  bladder-infection.  The  instrument,  having 
been  sterilized  and  lubricated,  is  introduced  without  difficulty  if  the  operator 


SURGERY  OF  THE  BLADDER  515 

remembers  that  its  curve  does  not  correspond  with  the  fixed  curve  of  the  normal 
urethra;  at  the  time  the  extremity  of  the  instrument  traverses  this  region  down- 
ward pressure  must  be  made  with  the  fingers  on  each  side  of  the  penis,  to 
straighten  out  the  urethral  curve.  Even  after  the  sound  has  traversed  the 
membranous  urethra  it  is  often  arrested  at  the  internal  vesical  sphincter,  and 
when  in  this  position  a  comparatively  roomy,  prostatic  urethra  may  allow  of 
some  degree  of  lateral  motion.  It  is  important  to  remember  that  the  sound  is 
not  satisfactorily  introduced  into  the  adult  bladder  unless  at  least  eight  inches 
of  the  straight  shaft  have  been  passed,  and  that  when  it  has  properly  entered  it 
can  be  easily  rotated  almost,  if  not  quite,  around  its  long  axis. 

The  bladder  having  been  entered,  the  cavity  of  this  viscus  should  be  sys- 
tematically explored.  The  sound  is  partly  withdrawn  and  pushed  back  again 
with  comparatively  rapid  motions,  the  handle  being  elevated  and  depressed. 
The  withdrawal  is  at  no  time  sufficient  to  engage  the  curve  of  the  instrument 
in  the  prostatic  urethra.  The  back  of  the  sound  should  then  be  turned  towards 
one  side  of  the  bladder,  and  the  point,  directed  towards  the  opposite  side,  should 
be  made  to  traverse  the  arc  of  a  circle,  sweeping  transversely  through  the 
bladder  from  above  downward.  This  motion,  begun  with  the  inner  end  of 
the  sound  at  the  bas-fond,  is  continued  while  the  sound  is  gently  drawn  out- 
ward until  the  curve  reaches  the  vesical  neck.  It  is  then  pushed  in  again  until 
the  posterior  wall  of  the  bladder  is  touched.  The  point  is  now  turned  to  the 
opposite  side  and  the  same  manoeuvre  is  repeated.  If  the  stone  is  not  found 
in  this  manner,  the  searcher  is  again  introduced  to  its  full  length,  and  the  tip 
is  turned  gently  towards  the  floor  of  the  bladder  and  rotated  quickly  from 
side  to  side,  while  the  instrument  is  gradually  withdrawn  until  its  curve  catches 
the  vesical  neck.  The  anterior  wall  of  the  bladder  may  be  explored  by  pressing 
it  down  by  suprapubic  pressure  till  the  tip  of  the  instrument  can  reach  its 
surface.  Where  there  is  an  enlarged  prostate  and  the  base  of  the  bladder  is 
depressed,  it  is  well  to  elevate  this  portion  of  the  viscus  by  a  finger  introduced 
Into  the  rectum,  while  the  exploration  with  the  sound  is  continued. 

If  these  manipulations  fail  to  detect  the  stone,  the  urine  should  be  gradually 
withdrawn,  and  as  the  bladder  contracts  they  should  be  repeated.  Thompson's 
searcher  should  be  used  under  such  circumstances. 

The  presence  of  stone  is  denoted  by  a  distinct  click,  which  can  be  both  felt 
and  heard.  The  feeling  is  that  of  a  sound  coming  in  contact  with  a  hard  body, 
the  click  like  that  of  a  piece  of  metal  striking  the  sound.  It  is  important  to 
bear  in  mind  that  this  click  should  be  heard  and  not  merely  felt.  The  attach- 
ment of  sounding-boards  or  of  tubes  to  the  searcher  is  of  no  practical  help 
to  the  surgeon  himself,  though  both  are  useful  for  class  demonstration.  Supra- 
pubic auscultation  is  said  to  be  helpful. 

The  size  of  the  stone  may  be  estimated  by  a  searcher  provided  with  markings 
on  its  shaft  and  with  a  sliding  collar  (Fig.  251).  By  passing  this  collar  to 
the  meatus  after  the  stone  is  first  touched,  and  then  marking  the  point  at 
which  the  sound  ceases  to  come  in  contact  with  it  as  it  is  slowly  withdrawn,  the 
diameter  of  the  stone  may  be  determined,  this  being,  of  course,  the  distance 
between  the  collar  and  the  meatus. 

The  surgeon  may  either  fail  to  detect  a  stone  which  is  present  or  imagine 


516  GENITO-URINARY  SURGERY 

he  has  detected  a  stone  which  is  not  present.  Failure  to  detect  a  stone  which 
is  present  may  be  due  to — 1,  the  more  or  less  encysted  condition  of  the  calculus, 
leaving  Uttle  or  none  of  its  surface  exposed;  2,  the  presence  of  a  diverticulum 
with  a  very  small  opening  containing  the  stone;  3,  the  fixation  of  the  stone  to  the 
summit  or  the  anterior  wall  of  the  bladder  by  adhesions;  4,  the  covering  of  the 
stone  with  lymph  or  blood-clot;  5,  the  lodgement  of  the  stone  in  a  deep  post- 
prostatic  sinus  or  between  the  lateral  or  upper  walls  of  a  prostatic  overgrowth 
and  the  vesical  mucosa;  6,  failure  to  enter  the  bladder  with  the  sound,  the 
prostatic  urethra  being  dilated  and  the  vesical  orifice  of  this  canal  being 
obstructed  by  prostatic  overgrowth. 

The  surgeon  may  believe  that  he  has  detected  stone  when  none  is  present 
from — (1)  incrustation  of  a  tumor  with  lime  salts;  (2)  a  trabeculated  con- 
dition of  the  bladder,  especially  when  associated  with  ulceration  and  partial 
incrustation;  (3)  bony  growths  developed  from  the  pelvis;  tumors,,  faecal  im- 
paction in  the  rectum;  and  undue  prominence  of  the  promontory  of  the  sacrum. 

Examination  by  the  lithotrite  is  of  advantage  in  enabling  the  surgeon  to 
determine  the  exact  size  of  the  stone„  to  ascertain  whether  or  not  it  is  adherent, 
and  to  make  a  rough  estimate  of  its  hardness.  As  a  means  of  simply  detecting 
the  stone  it  is  no  more  serviceable  than  a  stone-searcher  of  similar  curve,  and 
is  more  difficult  of  manipulation. 

The  evacuating-tube  attached  to  an  evacuator  is  probably  the  best  stone- 
searcher  if  the  calculus  is  very  small  and  moves  freely  in  the  bladder.  As 
the  liquid  in  the  evacuator  is  driven  forcibly  in  and  then  aspirated,  the  small 
calculus  will  be  brought  against  the  opening  of  the  catheter  with  a  sharp  and 
unmistakable  click.  It  should  be  noted  that  if  the  eye  of  the  tube  is  carried 
too  near  the  vesical  wall  this  will  be  sucked  in  and  will  give  a  jarring  sensation, 
or  if  the  joints  of  the  instrument  are  loose  there  may  be  produced  a  sound 
which  will  closely  simulate  the  click  of  a  stone.  This  instrument  is  useless  when 
the  stone  is  encysted  or  adherent. 

An  examination  with  a  cystoscope  is  of  service  as  a  means  of  finding  stones 
which  cannot  be  reached  by  the  sound,  corroborating  diagnosis,  determining 
whether  a  stone  is  adherent  or  encysted,  and  discovering  the  conditon  of  the 
vesical  mucosa. 

Prognosis. — A  vesical  calculus  may,  in  the  absence  of  cystitis,  from  the 
frequency  and  difficulty  of  micturition,  cause  hypertrophy  and  thickening  of 
the  bladder-walls,  dilatation  of  the  ureters  and  kidney  pelves,  and  a  chronic 
congestion  of  the  whole  urinary  tract,  strongly  favoring  infection.  Cystitis  once 
started  is  constantly  aggravated,  and  may  extend  deeply.  Exceptionally  the 
calculus  ulcerates  through  the  vesical  walls,  forming  a  pericystic  abscess  (Fig. 
254). 

From  constant  engorgement  the  prostate  slowly  enlarges,  and,  by  obstructing 
the  outflow  of  the  urine,  favors  retention,  with  reflux  of  septic  fluid  into  the 
ureters  and  kidney  pelves,  and  consequent  pyelonephritis.  Hence  the  prog- 
nosis of  untreated  calculus  is  grave. 

Prophylaxis. — The  presence  of  gravel  in  the  urine,  or  other  evidence  of 
supersaturation  with  solids,  'such,  for  instance,  as  heavy  deposits,  should  lead  to 
such  hygienic  and  dietetic  regulations  as  would  naturally  tend  to  lessen  the 


SURGERY  OF  THE  BLADDER 


517 


specific  gravity  of  the  urine  passed.  Of  prime  importance  is  the  careful  regu- 
lation of  digestion  by  appropriate  diet. 

Systematic  exercise  should  be  prescribed,  and  the  bowels  kept  fairly  soluble, 
preferably  by  salines  administered  in  the  morning  on  rising  and  at  night  just 
before  retiring.  This  latter  time  is  particularly  one  of  choice  in  the  case  of  an 
alkaline  mineral  water,  because  the  urine  naturally  becomes  most  acid  during 
the  small  hours  of  the  morning.  Supersaturation  of  the  urine  is  avoided  by 
diluting  it  with  water  or  bland  liquids.  These  must  not  be  taken  in  sufficient 
quantity  to  cause  indigestion.  Since  salt  renders  uric  acid  more  soluble,  it  is 
well  to  use  this  liberally  with  food. 

The  most  efficient  prophylaxis  is  based  on  keeping  the  bladder  free  from 
infection  {i.e.,  remedying  all  conditions  which  cause  straining  micturition  or 
residual  urine),  and  in  curing,  usually  by  efficient  drainage,  infection  when  it 
has  developed. 

Following  renal  colic,  the  surgeon  should  make  certain,  usually  by  the 
absence  of  vesical  symptoms,  that  the  calculus  has  passed  out  of  the  bladder; 
or  if  it  has  not,  and  probably  cannot  do  so  because  of  an  obstructive  lesion, 


Fig.  254. — Vesical  calculi.  A,  large  stone  'almost 
filling  main  cavity  of  bladder;  B,  stone  lying  within 
infected  pouch.  (No.  69-5-7.  From  Museum  of  Pathol- 
ogy, University  of  Pennsylvania.) 

should  remedy  this  by  means  of  Young's  punch  or  other  suitable  instrument 
at  the  time  of  the  removal  of  the  calculus. 

Alkaline  urine  will  slowly  dissolve  pure  uric  acid :  hence  when  for  any  reason 
operation  is  inadvisable,  it  would  seem  worth  while  to  render  an  acid  urine 
alkaline  by  the  administration  of  full  doses  of  potassium  citrate,  this  drug  being 
eHminated  as  the  carbonate.    There  is  no  instance  of  a  uric  acid  stone  having 


518 


GEXITO-URINARY  SURGERY 


been  perceptibly  reduced  in  size  by  this  treatment.  When  the  urine  shows 
excessive  phosphates,  a  tonic  treatment,  together  with  the  use  of  acid  sodium 
phosphate  (one  or  two  drachms  a  day),  or  nitrohydrochloric  acid,  is  indicated. 

TREATMENT   OF   VESICAL    CALCULUS 

Stones,  if  small,  may  be  removed  under  guidance  of  the  eye  mth  Young's 
cystoscopic  rongeur,  or  occasionally  may  be  washed  out  through  the  sheath  of 
a  cystoscope,  or  with  a  Bigelow's  evacuator.  If  movable,  accessible,  and  not 
too  large  and  hard,  stones  may  be  crushed  and  washed  out  (litholapaxy).  Or 
removal  may  be  effected  through  a  suprapubic  or  perineal  opening.  Whatever 
method  be  chosen,  a  preliminary  treatment  of  a  clinically  infected  bladder  is 
indicated,  usually  best  applied  by  the  continuous  catheter  and  mild  antiseptic 
flushings  through  it.  Nor  is  it  advisable  to  operate  during  the  exacerbation  of 
the  chronic  pyelonephritis  (see  p.  633)  from  which  the  prostatic  stone  case  so 
frequently  suffers.  The  internal  administration  of  urinary  antiseptics  for  one 
day  preceding  operation  and  two  days  afterward  is  desirable. 

Litholapaxy 

The  conditions  which  indicate  the  operation  are  a  stone  small  enough  to  be 
seized  in  the  jaws  of  the  lithotrite  (2  inches),  fragile  enough  to  be  broken  by 


Pig.  255. — Bigelow's  lithotrite. 


it  (practically  all  stones  not  more  than  an  inch  in  diameter),  and  so  placed 
that  the  manipulator  can  readily  grasp  it  and  afterwards  the  large  fragments 
which  result  from  the  first  breaking.    Moreover,  the  urethra  must  admit  without 


Fig.  256. — Weiss's  lithotrite. 

undue  trauma  at  least  a  32  instrument  if  the  patient  be  an  adult,  a  22  if  he 
be  a  child. 

The  crushing  instrument,  or  lithotrite,  devised  and  perfected  by  Bigelow 
(Fig.  255),  is  the  one  commonly  employed,  and  perhaps  is  more  satisfactory 
than  any  of  the  many  modifications  since  suggested  (Fig.  256). 

The  instrument  contains  a  male  and  a  female  blade,  so  arranged  that  they 
can  be  separated  or  approximated  by  a  sliding  motion.    As  soon  as  the  calculus 


SURGERY  OF  THE  BLADDER 


519 


is  grasped  the  blades  are  locked  by  a  turn  of  the  collar  of  the  handle;  this 
turn  at  the  same  time  brings  a  powerful  screw  in  proper  relation  with  a  set  of 
threads,  so  that  on  turning  the  knob  of  the  extremity  of  the  handle  the  male 
blade  is  forced  downward  and  thus  crushes  the  stone.  Especial  attention  is 
devoted  to  the  construction  of  the  jaws  and  teeth;  these  are  so  made  that 
clogging  by  the  lodgement  of  masses  of  crushed  calculi  is  impossible.  Instru- 
ments made  with  wide  fenestras  passing  completely  through  the  female  blade 
may  have  fragments  jam  so  firmly  that  to  remove  the  instrument  without 
laceration  of  the  urethra  suprapubic  cystotomy  may  be  required.  The  male 
blade— i.e.,  the  sliding  one — has  blunt,  pyramidal  projections  on  the  jaw,  so 
that  the  cusps  alone  catch  the  calculus.  As  the  latter  is  broken  the  fragments 
are  shed  to  the  sides,  instead  of  being  jammed  against  the  female  blade.  The 
latter  is  fenestrated  only  at  its  base,  to  receive  a  spur  on  the  base  of,  the  male 
blade,  thus  preventing  the  clogging  of  its  heel  by  small  fragments  (Fig.  257). 
The  tip  of  the  female  blade  is  slightly  prolonged  and  curved  back,  thus  allowing 
it  to  slide  readily  into  the  urethra,  and  also  lessening  the  danger  of  penetrating 
the  vesical  mucosa  as  the  blades  are  brought  together. 

This  instrument  is  powerful,  does  not  jam,  is  simple  in  construction,  and 


Fig.  257. — ^Jaws  of  Bigelow's  lithotrite. 

enables  the  operator  to  search  for  the  calculus,  grasp  it  and  crush  it  without 
taking  his  hands  from  the  handle. 

The  evacuating  instruments  are  full-sized  catheters,  straight,  or  with  a 
very  slight  curve,  at  the  end,  provided  with  eyes  fully  as  large  as  the  calibre 
of  the  tube,  and  an  aspirating  apparatus,  which  consists  of  a  thick  rubber  bulb 
with  a  wide-mouthed  glass  receiver  attached  below  and  an  opening  and  stopcock 
above,  so  that  it  can  be  completely  filled  with  water  (Fig.  258).  It  has  a 
double  stopcock  on  the  side,  the  latter  fitting  to  the  catheters  externally,  and 
internally  connecting  with  a  fenestrated  tube,  which  penetrates  one  or  more 
inches  into  the  bulb.  The  aggregate  emptying  power  of  these  fenestras  is 
greater  than  the  open  end  of  the  tube,  so  that  in  forcing  water  into  the  bladder 
it  rushes  in  through  these  small  lateral  holes  wdth  greater  velocity  than  through 
the  large  opening  at  the  end.  Thus  there  is  little  danger  that  fragments  will 
be  drawn  up  into  this  tube  from  the  receiver  and  driven  back  against  the  walls 
of  the  bladder. 

Operation. — ^Litholapaxy  may  be  performed  under  local  anaesthesia,  but 
as  a  rule  the  use  of  a  general  narcotic  is  preferable,  and  this  should  be  given 
to  the  extent  of  abolishing  the  bladder  reflex  and  securing  muscular  relaxation. 


520 


GENITO-URINARY  SURGERY 


The  urine  is  drawn,  and  the  bladder  is  irrigated  with  an  antiseptic,  either  silver 
1  to  5000  or  a  sterile  saturated  solution  of  boric  acid;  six  ounces  of  boric  acid 
solution  are  then  injected,  preferably  through  the  evacuator  which  the  surgeon 
intends  to  use,  as  it  is  then  certain  that  the  urethral  calibre  will  admit  it.  The 
patient  should  lie  upon  his  back,  the  shoulders  being  raised,  and  the  thighs  well 
separated  and  slightly  flexed;  the  posture  used  for  cystoscopy  is  suitable  (see 
p.  42).  The  lithotrite  is  introduced  exactly  as  a  sound  is  passed,  the  surgeon 
standing  at  the  patient's  left.  It  must  be  remembered  that  the  weight  of  the 
lithotrite  and  its  long  shaft  place  a  powerful  lever  in  the  hands  of  the  surgeon, 
which,  if  used  improperly,  may  cause  urethral  rupture.  When  the  beak  of  the 
instrument  has  entered  the  bladder,  the  handle  will  lie  between  the  thighs.  The 
surgeon  then  passes  to  the  patient's  right  and  manipulates  the  instrument  from 
that  side.     The  beak  should  be  gently  pushed  onward  until  it  touches  the 


Fig.  258. — Bigelow's  evacuator  and  tubes,  with  metal  cup  and  soft -rubber 
tube  for  filling. 

superior  wall  of  the  bladder,  when  the  blades  are  separated  until  the  male  blade 
touches  the  neck  of  the  bladder;  they  are  then  closed  rapidly.  If  the  calculus 
is  caught,  it  should  be  fixed  by  a  turn  of  the  collar  and  then  crushed  by  turning 
the  screw-handle.  If  the  calculus  is  not  caught  in  the  first  manoeuvre,  the  beak 
of  the  instrument  should  be  gently  turned  from  one  side  to  the  other,  alternately 
opening  and  closing  the  jaws  (Fig.  259).  If  it  still  eludes  the  grasp,  the  Htho- 
trite  should  be  turned  with  the  beak  directly  downward,  thus  exploring  the 
region  behind  the  prostate. 

Whenever  the  calculus  is  grasped  it  should  be  firmly  fixed  by  a  half-turn 
of  the  handle,  and  the  instrument  should  then  be  turned  so  that  its  beak  points 
upward,  and  be  withdrawn  so  that  the  stone  will  be,  as  nearly  as  can  be  guessed, 
in  the  centre  of  the  bladder.  By  this  manipulation  the  operator  can  assure 
himself  that  he  has  not  grasped  a  portion  of  the  mucous  membrane,  and  can 


SURGERY  OF  THE  BLADDER 


521 


proceed  to  crush  the  stone  by  rapidly  screwing  down  the  handle  (Figs.  260 
and  261).  These  manoeuvres  are  repeated  until  the  stone  is  reduced  to  small 
fragments.  Were  the  operation  to  terminate  here,  as  was  at  one  time  advised, 
it  would  be  lithotrity,  the  older  method  being  to  allow  patients  to  evacuate 


<■   .> 


Fig.  259. — -Opening  and  closing  the  blades  of  the  instrument  while 
searching  for  find  grasping  the  calculus. 


Fig.  260. — Crushing  a  small,  soft  calculus. 


522 


GENITO-URINARY  SURGERY 


by  natural  efforts  the  fragments  of  stone  thus  crushed.    This  is,  however,  unde- 
sirable, for  obvious  reasons. 

The  tightly  closed  lithotrite  having  been  withdrawn,  an  evacuating  catheter 
of  as  large  a  size  as  can  be  introduced  through  the  urethra  is  passed.  The 
extremity  of  this  instrument  being  kept  well  against  the  urethral  roof,  when 
it  reaches  the  membranous  portion  of  this  canal  its  outer  extremity  is  carried 


Fig.  261. — Crushing  a  large,  hard  stone. 


Fig.    262. — Evacuating    fragintrits    after   the  calculus    has    been 
crushed. 


SURGERY  OF  THE  BLADDER  523 

downward,  pressure  being  exerted  at  the  same  time  at  the  root  of  the  penis  by 
the  index  and  middle  finger  of  the  left  hand  placed  on  either  side  of  this  organ, 
thus  relaxing  the  suspensory  ligament  and  straightening  out  the  urethra.  This 
mancEuvre  is  especially  useful  when,  as  in  this  instance,  it  is  necessary  to  pass 
an  instrument  the  curve  of  which  is  less  than  the  fixed  curve  of  the  urethra. 

The  evacuating  bulb,  filled  with  warm  boric  acid  solution  or  sterile  water, 
is  then  connected  with  the  catheter,  the  stopcocks  between  the  two  are  turned 
on,  the  bubbles  of  air  contained  in  the  catheter  are  allowed  to  rise  to  the  top 
of  the  bulb  and  are  squeezed  out,  the  stopcock  there  being  turned  on  for  a 
moment,  and  then,  by  gentle  slow  pressure,  about  half  the  fluid  in  the  bulb  is 
allowed  to  pass  through  the  catheter  into  the  bladder.  After  waiting  a  few 
seconds  for  the  fragments  to  settle  about  the  base  of  the  bladder,  the  pressure 
on  the  rubber  bulb  is  suddenly  relaxed,  and  thus  the  fragments  are  sucked  up 
into  the  glass  receiver  (Fig.  262).  This  process  of  alternately  distending  the 
bladder  and  sucking  out  the  fluid  is  continued,  the  catheter  being  carried  in 
different  directions,  until  no  more  fragments  escape.  This  may  be  determined 
by  auscultation  over  the  bladder  during  the  process  of  aspiration,  any  frag- 
ments which  remain  being  heard  to  click  against  the  evacuating  catheter.  The 
catheter  should  then  be  withdrawn,  a  stone-searcher  or  cystoscope  introduced, 
and  careful  search  made  for  any  remaining  calculus;  none  being  found,  the 
operation  has  been  completed. 

In  place  of  the  aspirating  instrument  used  by  Bigelow,  it  is  worthy  of  note 
that  if  the  fragment  is  thoroughly  pulverized  the  natural  expulsive  force  of  the 
bladder  is  sufficient  entirely  to  evacuate  the  fragments.  This  may  be  accom- 
plished by  introducing  a  full-sized  catheter,  distending  the  bladder  by  a  gra\dty- 
bag  or  syringe,  then  allowing  the  contents  to  flow  away  in  a  full-sized  stream. 
It  is  obvious,  however,  that  this  method  of  evacuation  is  not  so  sure  as  that 
proxided  by  the  Bigelow  apparatus. 

The  only  serious  complication  liable  to  occur  during  the  course  of  litho- 
lapaxy  is  the  clogging  of  the  blades.  This  should  be  obviated  by  rapping  them 
sharply  and  quickly  together  several  times.  If  this  manoeuvre  fails,  the  tip 
of  the  instrument  should  be  brought  up  against  the  pubis  and  suprapubic 
cystotomy  performed.  In  case  the  bladder  should  be  ruptured,  immediate 
suprapubic  cystotomy  and  drainage  would  be  indicated. 

The  further  treatment  is  so  directed  that  the  patient  is  kept  quiet  in  bed 
on  a  restricted  diet  for  two  days  to  a  week,  or  until  pus  and  blood  disappear 
from  the  urine.  During  this  time  hexamethylenamine  or  salol  is  given  by  the 
mouth  and  the  bowels  are  kept  open  by  enemata. 

Guyon  warmly  commends  the  retained  catheter  as  an  after-treatment  of 
litholapaxv',  keeping  it  in  place  for  twenty-four  hours.  Many  of  his  cases  had 
been  infected  for  a  long  time,  and  were  old  prostatics  with  phosphatic  calculi, 
the  class  in  whom  vesical  operation  is  likely  to  result  fatally.  His  results  were 
most  favorable,  and  seemed  to  indicate  that  the  retained  catheter  distinctly 
lessens  mortality  in  infected  prostatics  with  vesical  calculi. 

Chismore  describes  a  modification  of  the  Bigelow  operation  employed  by 
him  in  fifty-two  cases.  His  patients  were  all  old,  and  many  of  them  were  pros- 
tatics.    He  had  no  deaths.     He  believes  that  his  method  is  particularly  ap- 


524  GENITO-URINARY  SURGERY 

plicable  to  cases  of  senile  atrophy  with  pouched  or  irregular  bladder.  These 
conditions,  together  with  the  consequent  alterations  of  the  vesical  orifice  of 
the  urethra,  make  it  impossible  to  command  considerable  portions  of  the  cavity 
of  the  bladder  with  the  lithotrite,  or  indeed  with  any  instrument  introduced 
into  the  urethra  or  through  a  perineal  incision,  besides  favoring  the  escape  and 
retention  of  fragments  of  calculi  during  litholapaxy. 

Chismore  used  local  anaesthesia,  and  conducted  his  crushings  in  a  series  of 
short  office  sittings.  He  emptied  the  bladder,  injected  one  or  two  fluidounces 
of  a  four  per  cent,  solution  of  cocaine  hydrochlorate,  gently  inserted  the  litho- 
trite and  seized  and  crushed  the  stone.  He  continued  to  crush  so  long  as 
fragments  were  readily  found,  washed  out  the  pieces,  and  stopped  the  momient 
spasm  of  the  bladder,  unusual  distress,  or  symptoms  of  exhaustion  occurred. 
According  to  his  method,  if  pieces  are  left  after  the  first  crushing,  these  are 
removed  after  the  reaction  due  to  the  operation  has  subsided,  and  their  presence 
can  be  recognized  with  stone-searcher  or  cystoscope,  usually  within  a  week. 
The  partial  operation  with  evacuation  of  the  fragments  is  then  repeated  until 
the  bladder  is  clear. 

The  male  blade  of  Chismore's  lithotrite  is  hollow,  and  is  attached  to  an 
evacuatoi"  of  simple  and  ingenious  construction.  As  the  stone  is  crushed  it  is 
evacuated  through  the  male  blade.  This  avoids  repeated  passing  of  instru- 
ments, and  is  also  a  valuable  means  of  drawing  into  the  grip  of  the  lithotrite 
calculi  which  otherwise  could  not  be  reached;  for  when  the  instrument  is  opened, 
if  the  bulb  of  the  evacuator  is  compressed  and  then  suddenly  released,  fine 
fragments  will  be  drawn  through  the  cannula  of  the  male  blade  and  into  the 
receptacle  placed  externally,  while  fragments  too  large  to  pass  will  be  sucked 
exactly  into  the  grip  of  the  instrument.  This  operation  may  be  conducted  in  the 
office.  Following  operation  there  is  usually  an  immediate  sense  of  relief;  the 
reaction  is  slight.  The  patient's  sensations  prove  a  valuable  guide  as  to  the 
presence  or  absence  of  further  fragments. 

There  has  long  been  a  popular  belief  that  in  children  lithotomy  is  a  safer 
operation  than  litholapaxy.  Statistics  have  established  beyond  cavil  the  greater 
safety  of  the  latter  operation. 

Cabot  and  Barling  record  for  perineal  lithotomy,  602  cases,  19  deaths, — a 
percentage  of  3.1;  suprapubic  lithotomy,  637  cases,  84  deaths — a  mortality 
of  13.1  per  cent.;  litholapaxy,  284  cases,  5  deaths, — a  mortality  of  1.7  per 
cent. 

No  age  is  exempt  from  calculus,  since  it  has  been  found  in  the  foetal  bladder. 
About  half  of  all  cases  of  vesical  stone  are  observed  in  children:  hence  in  them 
operation  for  its  removal  is  frequently  required.  Keegan  states  that  the  urethra 
of  a  child  from  three  to  six  years  of  age  will  usually  accommodate  a  No.  6  to 
No.  8  English  lithotrite,  while  a  No.  12  to  No.  14  can  be  passed  into  the 
urethra  of  a  child  of  eight  to  ten  years. 

Otis  has  shown  that  in  children  as  in  adults  the  small  diameter  of  the 
urethra  may  be  greatly  increased  with  entire  safety.  He  states  that  the  pro- 
portionate relation  between  the  circumference  of  the  urethra  and  that  of  the 
penis  which  he  believes  to  exist  in  adults  holds  good  in  children.  Thus,  with 
a  penile  circumference  of  one  and  a  half  inches,  as  in  a  child  from  two  ta 


SURGERY  OF  THE  BLADDER  525 

three  years  of  age,  the  size  of  the  urethra  would  not  be  less  than  fifteen  milli- 
metres. For  every  quarter  of  an  inch  added  to  the  penile  circumference  two 
millimetres  may  be  added  to  the  urethral  calibre.  It  should  be  remembered 
that  this  indicates  rather  the  distensibility  than  the  actual  calibre  of  the  canal. 

Recurrence  of  stone  may  be  observed  after  any  operation.  Keegan  after 
an  extended  experience  is  convinced  that  this  recurrence  in  male  children  does 
not  follow  litholapaxy  oftener  than  it  follows  lithotomy. 

The  urethra  and  bladder  of  children  are  tolerant  of  instrumentation:  hence 
litholapaxy  is  advised  for  small  stones  or  those  of  moderate  size  (from  three- 
fifths  to  four-fifths  of  an  inch  in  diameter),  and  for  larger  stones  lithotomy. 
It  is  fairly  easy  to  determine  the  approximate  size  of  calculi  in  children  by 


Fig.     263. — Uric    acid    calculus.       Exact    size.       Weight, 
nine  and  one-half  ounces.    Removed  by  suprapubic  section. 

bimanual  palpation.  Guided  by  this,  or  by  the  cystoscopic  appearance,  the 
appropriate  method  is  selected. 

In  children  litholapaxy  is  the  operation  of  choice  when  the  surgeon  is  pro- 
vided with  at  least  two  lithotrites  of  proper  size,  with  evacuating  tubes  and 
smoothly  working  aspirator,  and  has  had  previous  experience  in  the  use  of  simi- 
lar instruments  on  the  adult.  Since  few  surgeons  have  either  the  tools  or  the 
skill  to  use  them,  and  fewer  still  this  desirable  combination,  the  cutting  operation 
remains  the  one  of  choice  in  the  majority  of  cases. 

In  children  it  is  especially  important  that  the  instrument  should  be  withdrawn 
and  reintroduced  as  seldom  as  possible.  A  lithotrite  which  fits  .the  urethra 
tightly  should  not  be  used,  since  the  entrance  of  the  calculus  sand  into  the 
urethra  may  render  the  withdrawal  of  the  full-sized  instrument  exceedingly  diffi- 


526  '  GENITO-URINARY  SURGERY 

cult.'  This  also  interferes  with  the  introduction  of  evacuating  tubes  of  adequate 
size.  In  seeking  for  or  attempting  to  seize  the  stone,  care  should  be  taken  to 
avoid  such  wide  separation  of  the  blades  as  will  bring  the  male  blade  in  frequent 
contact  with  the  vesical  neck.  The  crushing  should  invariably  be  done  only  after 
wide  separation  of  the  blades  as  will  bring  the  male  blade  in  frequent  contact 
with  the  vesical  neck.  The  crushing  should  invariably  be  done  only  after 
rotating  the  blades  into  the  centre  of  the  bladder.  Every  particle  of  the  cal- 
culus should  be  evacuated.  Copious  irrigation  of  the  anterior  urethra  through 
a  soft  catheter  carried  to  the  compressor  urethrae  muscle  aids  in  freeing  it  from 
fine  solid  particles  which  may  be  lodged  on  its  surface. 

After  crushing  and  evacuation  the  bladder  is  thoroughly  irrigated  and  sub- 
jected  to  cystoscopic  examination   for   remaining   fragments.     Thereafter  an 


Fig.   264. — Uric  acid  calculus.     Exact  size.     Weight,  nine  and 
one-half  ounces.     Removed  by  suprapubic  section. 

indwelling  catheter  is  employed  or  not  in  accordance  with  the  severity  of 
the  preceding  cystitis  and  the  thoroughness  with  which  all  fragments  have  been 
evacuated. 

CoNTRA-iNDicATioNS  TO  LiTHOLAPAXY  are — Inexperience  on  the  part  of 
the  surgeon  with  the  handling  of  the  needful  instruments;  difficulty  in  their 
passage;  a  stone  so  placed  or  of  such  size  and  hardness  that  it  cannot  be  seized 
or  crushed  (Figs.  263  and  264) — these  conditions  should  cause  other  treatment 
than  htholapaxy  to  be  selected. 

Statistics  of  operation  performed  upon  calculus  patients  ranging  from 
puberty  to  middle  age  are  as  follows:  perineal  lithotomy,  226  cases,  22  deaths, 
9.7  per  cent.;  suprapubic  lithotomy,  159  cases,  18  deaths,  11.3  per  cent.; 
Htholapaxy,  485  cases,  22  deaths,  4.5  per  cent. 

The  greater  safety  of  Htholapaxy  in  old  age,  as  shown  by  statistical  evidence, 


SURGERY  OF  THE  BLADDER  527 

is  even  more  striking  than  in  childhood  or  middle  age.  Perineal  lithotomy,  69 
cases,  13  deaths,  19  per  cent.;  suprapubic  lithotomy,  91  cases,  17  deaths,  18 
per  cent.;  litholapaxy,  581  cases,  40  deaths,  7  per  cent.  In  old  age  the  usual 
contra-indication  to  litholapaxy,  in  addition  to  those  mentioned  as  applying 
from  puberty  to  middle  age,  is  enlargement  of  the  prostate  so  pronounced  that 
the  lithotrite  either  cannot  be  introduced,  or  if  successfully  passed  cannot  reach 
the  stone,  even  though  an  effort  be  made  to  lift  this  from  the  post-prostatic 
pouch  by  a  finger  in  the  rectum. 

Complications  of  Litholapaxy. — It  may  happen  that  the  surgeon,  having 
taken  it  for  granted,  because  of  the  history  of  the  patient,  that  the  urethra  will 
receive  his  instruments,  finds  some  obstruction  which  prevents  them  from  passing. 
Usually  this  is  because  of  a  narrow  meatus.  In  that  case  it  is  at  once  obviated 
by  meatotomy.  It  may  be  from  an  anterior  stricture.  This  should  be  treated 
by  internal  urethrotomy,  the  patient  then  wearing  a  continuous  catheter  for  a 
few  days  after  litholapaxy.  If  the  stricture  is  deep  and  dense,  this  indicates 
median ,  perineal  lithotomy  or  litholapaxy  together  with  urethrotomy.  If  the 
obstruction  is  in  the  prostate  and  cannot  be  overcome  without  the  use  of  force, 
the  crushing  operation  must  be  abandoned. 

It  may  happen  that  though  the  urethra  receives  the  lithotrite,  the  smallest 
evacuating-tube  which  the  surgeon  has  fails  to  pass.  If  the  stone  is  crushed 
before  this  is  discovered,  it  constitutes  an  embarrassing  complication,  since,  even 
after  the  finest  practicable  fragmentation,  it  is  unsafe  to  allow  the  fragments  to 
be  passed  through  the  urethra.  It  is  with  the  idea  of  avoiding  this  complication 
that  we  have  advised  injection  of  the  bladder  through  the  evacuating-tube  which 
the  surgeon  intends  to  use.  He  will  then  discover  before  having  crushed  the 
stone  that  the  tube  cannot  be  passed,  and  can  either  procure  a  smaller  tube  or 
at  once  proceed  to  remove  the  stone  by  the  appropriate  cutting  operation. 

If  the  stone  has  been  crushed  and  no  evacuator  can  be  introduced,  cys- 
totomy should  be  performed  and  the  fragments  removed  by  the  scoop  and 
irrigator. 

The  lithotrite  may  jam  with  the  blades  so  widely  open  that  their  withdrawal 
when  in  this  position  would  almost  certainly  entail  laceration  of  the  urethra. 
If  a  series  of  quick  jarring  closures  fail  to  free  the  blades,  they  should  be  turned 
forward  against  the  anterior  surface  of  the  bladder  and  be  cut  down  upon  above 
the  pubis;  or  they  may  be  reached  and  cleared  by  perineal  incision.  Bending 
of  the  blades  may  require  similar  operations.  Should  the  blades  break,  the 
shaft  should  be  removed,  if  possible,  without  the  exertion  of  force;  the  frag- 
ments can  then  be  taken  out  by  a  median  perineal  operation.  It  is  to  the  credit 
of  the  instrument-makers  that  very  few  lithotrites  have  been  bent  or  broken 
in  crushing  stones. 

The  bladder  may  be  ruptured  during  preliminary  injection  or  during  at- 
tempts at  evacuation  of  the  stone  fragments.  Rupture  during  injection  would 
be  suggested  were  it  found  impossible  to  move  the  blades  of  the  lithotrite  freely 
in  the  bladder  for  want  of  room,  thus  showing  it  to  be  partly  or  completely 
empty.  If  this  accident  occurred  during  the  use  of  the  evacuator,  unusually 
free  bleeding  would  be  noted,  and  the  liquid  injected  would  fail  to  return,  the 
mucous  membrane  being  constantly  sucked  into  the  eye  of  the  evacuating-tube, 
in  whatever  position  this  might  be  placed. 


528  GENITO-URINARY  SURGERY 

As  sequelae  of  litholapaxy  there  may  develop — (1)  Shock  or  collapse,  re- 
sulting fatally  in  a  few  hours,  (2)  Hemorrhage.  (3)  Suppression  of  urine, 
which  may  be  fatal  in  one  or  two  days.  This  is  observed  in  old  persons  with 
crippled  kidneys,  in  whom  the  slightest  interference  is  liable  so  to  disturb  equi- 
librium that  the  kidneys  become  insufficient.  (4)  Urinary  fever.  This  may 
be  transitory,  passing  off  in  from  twenty-four  to  forty-eight  hours,  or  may 
develop  into  a  true  septicaemia.  (5)  Ascending  pyelonephritis,  with  the  de- 
velopment of  surgical  kidney.  (6)  Prostatitis  and  epididymitis.  (7)  Pelvic 
cellulitis  extending  from  a  pericystitis.  (8)  Phlebitis  involving  primarily  the 
prostatic  plexus,  sometimes  extending  to  the  whole  pelvic  venous  system,  and 
causing  extensive  thrombosis  with  oedema  of  the  legs,  or  septic  embolism  and 
death  from  pyaemia.  (9)  Peritonitis.  This  may  be  caused  by  extension  of 
inflammation  due  to  trauma  inflicted  on  the  bladder  wall.  With  the  exception 
of  uraemia  of  the  aged,  these  complications  are  rare  if  proper  care  is  taken,  and 
can  be  readily  avoided. 

Lithotomy 

Lithotomy  means  an  incision  into  the  bladder  for  the  removal  of  stone.  The 
bladder  may  be  opened  through  the  perineum  by  lateral,  bilateral,  median,  or 
mediobilateral  incisions.  It  may  be  opened  through  the  abdominal  walls  by  a 
suprapubic  incision. 

Perineal  Lithotomy. — ^This  operation,  because  of  its  low  mortality,  ease 
and  speed  of  performance,  and  adequacy  to  meet  the  known  indications  as 
ascertained  by  cystoscopic  examination,  would  be  the  one  of  choice  in  approach- 
ing the  bladder  but  for  the  fact  that  through  the  opening  thus  made  neither 
jeady  inspection  nor  comfortable  palpation  is  possible;  nor  is  the  damage  done 
to  the  prostatic  urethra  and  ejaculatory  ducts  entirely  negligible. 

In  all  forms  of  perineal  lithotomy  the  following  anatomical  landmarks  should 
be  considered.  The  perineum  is  triangular  in  form,  having  its  apex  at  the 
symphysis  pubis,  and  for  its  boundaries  the  rami  of  the  ischia  and  pubis  later- 
ally, and  an  imaginary  line  passing  through  the  centre  of  the  anus  and  connect- 
ing the  tuberosities  of  the  ischia.  The  perineal  centre  is  a  point  midway 
tetwen  the  centre  of  the  anus  and  the  perineo-scrotal  junction;  it  marks  the 
middle  of  the  lower  edge  of  the  triangular  ligament.  Just  in  front  of  this  point 
are  the  bulb  of  the  penis  and  its  arteries.  The  raphe  extends  in  the  mid-perineal 
line  from  the  anterior  edge  of  the  anus  up  over  the  scrotum.  Beneath  it  there 
are  no  arteries  of  importance. 

The  depth  of  tissue  between  the  skin  and  the  bladder  in  the  male  adult 
varies  from  two  and  a  half  to  three  inches  when  measured  near  the  base  line 
of  the  perineum. 

Lateral  Lithotomy. — The  following  instruments  are  needed  for  the  lateral 
operation:  a  scalpel  with  a  three-inch  blade  and  a  moderately  heavy  handle;  a 
probe-pointed  bistoury,  for  enlarging  the  prostatic  incision,  should  this  be 
necessary;  a  large  curved  lithotomy  staff  (Fig.  265),  grooved  on  the  under  sur- 
face; the  groove  should  be  deep  enough  to  prevent  the  knife  from  slipping  out 
when  once  engaged;  straight  and  curved  lithotomy  forceps  (Fig.  266),  the 
straight  answering  for  most  purposes  except  when  the  calculus  is  lodged  in  a 


SURGERY  OF  THE  BLADDER 


529 


pouch  posterior  to  the  prostate,  when  the  curved  forceps  will  be  required;  a 
scoop  (Fig.  267)  for  dislodging  the  calculus  from  a  sacculation,  for  removing 
debris,  etc.;  a  catheter  en  chemise,  or  a  Buckston-Browne  air-tampon,  for  con- 
trolling hemorrhage,  should  it  be  excessive. 

The  catheter  en  chemise  is  made  by  passing  a  gum  catheter  through  the 
centre  of  a  piece  of  gauze  or  muslin  "four  inches  square;  the.  muslin  is  slipped 
along  the  catheter  till  it  is  about  one  inch  from  its  eye;    it  is  then  firmly 


Fig.  265. — Grooved  lithotomy  stafE. 


wrapped  with  silk  about  the  point  of  puncture,  thus  securing  it  in  place  and 
allowing  the  muslin  or  gauze  to  hang  free  as  would  a  petticoat.  When  needed 
to  stop  bleeding,  this  catheter  is  passed  into  the  bladder  through  the  wound, 
and  the  space  intervening  between  the  muslin  and  the  catheter  shaft  is  then 
packed  with  iodoform  or  other  antiseptic  gauze.     Buckston-Browne's  air-tam- 


FiG.  266. — Stone  forceps  (curved). 

pon  acts  as  does  the  Barnes  bag,  being  inflated  after  it  has  been  put  in  position: 
the  air-bag  surrounds  a  catheter. 

A  Hthotrite  should  be  provided,  in  case  the  stone  should  be  too  large  to  be 
removed  whole,  and  also  the  surgical  instruments  required  in  all  cutting  opera- 
tions,— i.e.,  knives,  scissors,  dissecting  forceps,  haemostatic  forceps,  tenacula, 
grooved  director,  and  probe.  Preliminary  disinfection  of  the  urethra  and  the 
operative    region   having   been    accomplished,    and    the   rectum    having   been 


Fig.  267. — Calculus  scoop. 

emptied,  the  patient,  thoroughly  anaesthetized,  is  placed  on  the  table.  Previous 
to  beginning  the  operation  the  stone  is  again  sought  for;  unless  it  is  found  at 
this  time,  the  operation  should  be  postponed.  If  it  is  detected,  the  urine  is 
drawn  by  a  catheter,  and  from  six  to  eight  ounces  of  boric  acid  solution  or  other 
antiseptic  are  injected;  the  patient  is  then  brought  to  the  edge  of  the  table  with 
his  thighs  well  separated  and  flexed  on  the  abdomen  and  the  legs  flexed  on  the 
thighs,  the  position  being  maintained  either  by  assistants  or  by  mechanical 
contrivances.  The  buttocks  should  project  slightlv  over  the  end  of  the  table 
34 


530  GENITO-URINARY  SURGERY 

The  grooved  staff  is  then  passed  into  the  urethra.  Its  tip  being  well  within 
the  bladder,  the  curve  of  the  staff  is  pulled  up  against  the  symphysis;  its  shaft 
should  be  exactly  in  the  middle  line  or  inclined  a  little  towards  the  right  groin. 
The  surgeon,  having  placed  the  staff  as  he  wishes  it,  directs  an  assistant  to 
hold  it  exactly  in  this  position.  The  incision  is  made  from  a  point  an  inch 
and  a  quarter  in  front  of  the  anus  and  a  little  to  the  left  of  the  raphe,  down- 
ward and  outward  for  three  inches,  to  about  the  middle  of  the  space  between 
the  anus  and  the  tuberosity  of  the  ischium,  inclining  slightly  more  towards  the 
ischium  to  avoid  injuring  the  rectum.  The  first  incision  is  deeper  anteriorly, 
and  divides  the  skin,  superficial  fascia,  transverse  perineal  muscle,  a  few 
posterior  fibres  of  the  accelerator  urinae,  branches  of  the  superficial  perineal  ves- 
sels and  nerve,  and  the  inferior  edge  of  the  superficial  layer  of  the  triangular 
Hgament;  at  the  posterior  portion  of  the  incision  the  inferior  hemorrhoidal 
vessels  and  nerves  are  laid  bare.  All  freely  bleeding  vessels  are  at  once  secured 
by  haemostatic  forceps,  which  are  not  removed  till  the  operation  is  completed. 
The  space  containing  the  membranous  urethra  bounded  by  the  superficial  and 
deep  layers  of  the  triangular  ligament  having  been  thus  opened,  the  surgeon 
introduces  his  finger  into  the  wound  and  feejs  for  the  groove  of  the  staff. 
Finding  it,  and  with  his  left  forefinger  as  a  guide,  the  point  of  the  knife  is 
passed  into  the  groove,  and,  by  either  pushing  the  staff  and  knife  backward 
together  or  following  the  groove  with  the  point  of  the  knife,  the  bladder  is 
entered  at  its  neck.  To  extract  the  calculus  easily  it  is  necessary  to  incise  the 
left  lobe  of  the  prostate:  this  is  accomplished  by  depressing  the  knife  so  that 
the  greatest  cutting  pressure  is  brought  to  bear  on  the  heel  of  the  blade.  The 
blade  of  the  knife  should  be  kept  parallel  with  the  external  wound.  This  cut 
divides  the  deep  layer  of  the  triangular  ligament,  the  anterior  fibres  of  the 
levator  ani,  a  portion  of  the  compressor  urethrae  muscle,  the  left  lobe  of  the 
prostate,  the  membranous  and  the  prostatic  urethra,  and  nicks  the  vesical  neck. 
A  deep  incision  into  the  neck  of  the  bladder  may  cause  serious  hemorrhage 
from  wounding  of  the  prostatic  plexus  of  veins,  or,  by  opening  the  recto-vesical 
fascia,  may  allow  of  urinary  infiltration.  If  the  staff  is  kept  well  up  against  the 
pubis  and  the  blade  of  the  knife  is  not  permitted  to  leave  its  groove,  the 
incision  into  the  prostate  and  the  neck  of  the  bladder  is  not  likely  to  be  too 
deep.  The  entrance  of  the  knife  into  the  bladder  is  marked  by  a  rush  of  urine 
or  of  the  fluid  injected.  The  prostatic  wound  may  be  enlarged  during  the 
withdrawal  of  the  knife,  endangering  the  rectum.  The  better  plan  is  to  make 
the  wound  as  free  as  is  required,  by  depressing  the  handle  during  the  passage 
of  the  knife  inward,  when  its  tip  is  engaged  in  the  groove  of  the  staff.  Having  • 
thus  opened  the  prostatic  urethra  and  the  vesical  neck,  the  left  forefinger  of 
the  operator,  guided  by  the  groove  of  the  staff,  is  introduced  into  the  bladder; 
when  the  stone  is  felt  the  staff  is  withdrawn. 

The  operator's  finger  being  within  the  bladder,  the  closed  forceps  is  intro- 
'duced  along  this  as  a  guide  until  the  blades  are  well  inside.  It  is  then  opened 
and  rotated  on  its  long  axis  to  the  right,  thus  enabling  the  right-hand  blade  to 
act  as  a  scoop,  which  slides  beneath  the  calculus.  WTien  the  stone  is  firmly 
grasped  in  the  forceps  it  is  removed  by  traction  made  upward  and  forward  in 
the  line  of  the  pelvic  axis.    A  slight  rocking  motion  often  assists  in  its  delivery. 


SURGERY  OF  THE  BLADDER  531 

When  the  stone  is  oblong  or  irregular  in  shape  it  is  important  so  to  grasp  it 
that  its  smallest  dimensions  shall  be  presented  to  the  opening. 

In  children  the  use  of  a  blunt  gorget  is  of  use,  owing  to  the  prostate  being 
a  rudimentary  body  and  the  vesical  neck  not  being  of  sufficient  size  to  allow 
of  the  introduction  of  the  finger.  The  forceps,  guarded  by  the  curved  surface 
of  the  gorget,  are  introduced,  with  somewhat  more  of  an  inclination  towards 
the  symphysis  than  in  the  adult,  owing  to  the  relatively  high  position  of  the 
bladder  in  children. 

Failure  to  find  the  calculus  at  the  first  trial  may  be. due  to  its  lodgement 
behind  the  prostate.  Repeating  the  attempt  and  meeting  with  no  success,  the 
curved  forceps  should  be  substituted  and  introduced  with  the  points  downward 
and  the  handle  slightly  raised,  when  the  calculus  will  usually  be  found.  If  the 
calculus  cannot  be  removed,  owing  to  the  edges  of  the  wound  overlapping,  the 
fingers  may  be  used  as  retractors  or  a  sufficient  incision  made  with  the  probe- 
pointed  knife,  the  incision  being  preferable  to  tearing  the  wound  in  the  effort 
of  extraction.  The  bladder  should  be  explored  with  either  the  finger  or  a 
sound  after  the  stone  has  been  extracted,  to  be  certain  that  no  other  stone 
remains.  Every  portion  of  its  walls  should  be  felt.  This  is  facilitated  by 
making  suprapubic  pressure  while  the  examining  finger  is  in  the  bladder. 

Soft  calculi,  by  breaking  into  several  pieces  from  the  pressure  of  the  for- 
ceps, usually  prolong  the  operation  and  necessitate  the  use  of  a  scoop  and  careful 
irrigation  in  order  that  all  the  fragments  may  be  removed.  In  spite  of  every 
precaution  a  small  fragment  may  remain,  forming  a  nidus  for  new  concretions. 
Recurrence  of  stone,  however,  does  not  prove  that  operation  was  incomplete, 
this  frequently  taking  place  when  it  is  absolutely  certain  that  the  bladder  has 
been  emptied. 

Other  complications  may  occur.  Among  them  is  excessive  hemorrhage 
following  the  first  incision,  and  due  to  wounding  of  the  artery  of  the  bulb, 
either  from  its  anomalous  position  or  because  the  incision  is  carried  too  far 
forward;  or  the  distended  hemorrhoidal  vessels  may  be  the  source  of  the 
bleeding.  Hemorrhage  from  such  a  source  is  easily  controlled  by  means  of 
haemostatic  forceps,  replaced  by  ligatures  at  the  termination  of  the  operation. 

Hemorrhage  from  the  deeper  incision  is  rarely  profuse,  and  usually  stops 
from  the  pressure  of  the  fingers  or  of  the  instruments  introduced.  These 
proving  insufficient,  a  catheter  en  chemise,  or  a  Buckston-Browne  tampon,  may 
be  inserted  after  the  removal  of  the  calculus;  this  usually  controls  it. 

Through  careless  manipulation  the  staff  may  not  enter  the  bladder,  but 
may  be  caught  in  a  pouch  of  the  urethra.  Should  such  an  accident  occur, 
the  staff  should  be  withdrawn  and  reintroduced  until  it  is  brought  in  contact  with 
the  stone. 

It  has  happened  in  lithotomies  performed  on  children  that,  owing  to  the 
small  size  of  the  incision  in  the  vesical  neck  and  the  prostate,  efforts  at  intro- 
ducing the  finger  into  the  bladder  have  resulted  in  tearing  the  membranous 
urethra  completely  across  and  pushing  the  bladder  up  out  of  the  pelvis.  Such 
an  accident  demands  suprapubic  cystotomy,  the  suturing  of  the  torn  ends  of 
the  urethra,  and  the  passage  of  a  catheter  from  the  bladder  out  through  the 
urethra. 


532  GENITO-URINARY  SURGERY 

Wounding  the  rectum,  due  to  insufficient  lateralization  of  the  knife,  some- 
times occurs;  the  wound  usually  heals  spontaneously,  though  a  fistula  may 
follow.  To  guard  against  such  a  result,  the  rectal  wound  should  be  stitched 
as  soon  as  discovered. 

Peritonitis  has  resulted  from  opening  the  posterior  wall  of  a  contracted 
bladder:  to  obviate  such  an  accident,  the  bladder  should  be  moderately  dis- 
tended with  fluid,  and  the  knife  should  not  be  carried  too  far  forward  into 
the  wound. 

The  perineum  may  be  so  deep  that  it  will  be  impossible  to  introduce  the 
finger  into  the  bladder  to  guide  the  forceps  to  the  stone.  Should  such  perineal 
depth  be  anticipated,  suprapubic  operation  should  be  chosen.  When  this  con- 
dition is  discovered  after  the  incision  has  been  made,  a  blunt  gorget,  with  thin 
but  not  sharp  edges,  may  be  used  to  guide  the  forceps,  the  gorget  being  with- 
drawn as  soon  as  the  stone  is  grasped. 

Prostatic  enlargement  or  fibrosis  of  the  internal  sphincter  may  necessitate 
the  use  of  the  gorget  as  a  guide  instead"  of  the  finger.  In  these  cases  there  may 
be  such  extreme  rigidity  of  the  neck  of  the  bladder  that  full  dilatation  of  the 
prostatic  urethra  will  be  required  before  instruments  for  the  extraction  of  the 
stone  can  be  passed.  A  pair  of  straight  or  curved  Spencer-Wells  forceps, 
opened  out  after  introduction  into  the  wound  along  the  groove  of  the  staff,  is 
then  serviceable.  Forcible  dilatation  of  the  prostatic  urethra  may  be  followed 
by  complete  disappearance  of  the  urinary  symptoms. 

It  may  be  hard  to  complete  the  operation  because  of  the  size  of  the  stone, 
A  calculus  over  two  inches  in  diameter  could  scarcely  be  removed  through  the 
perineal  opening  unless  the  incision  were  dangerously  large  or  the  tissues  seri- 
ously bruised.  Cystoscopic,  X-ray,  and  bimanual  palpation  should  always  de- 
tect a  stone  of  this  size,  and  should  prevent  the  surgeon  from  making  efforts 
at  removal  by  perineal  operation.  In  case  previous  examination  has  been 
neglected  and  the  bladder  is  already  open,  the  stone  may  be  crushed  and  re- 
moved in  fragments. 

Sacculation  may  make  the  removal  of  the  stone  through  the  perineum  im- 
possible.    This  condition  calls  for  the  suprapubic  cut. 

After-Treatment  of  Perineal  Lithotomy  Cases. — The  bladder,  having 
been  cleared  of  calculi  and  incrustations,  should  be  well  irrigated  with  hot  sterile 
salt  solution  or  protargol  (1  to  4000)  (110°  F.).  This  removes  small  fragments 
and  clots  and  serves  to  control  hemorrhage. 

Should  hemorrhage  from  the  bladder-neck  or  the  prostate  persist,  the  air- 
tampon  or  the  catheter  en  chemise  is  inserted.  This  may  be  removed  within 
forty-eight  hours. 

When  there  is  cystitis,  particularly  if  this  is  of  long  standing,  perineal 
drainage  is  indicated.  This  is  best  secured  by  a  full-sized  gum  catheter  (30  F.) 
the  tip  of  which  lies  just  within  the  vesical  sphincter.  A  rubber  tube  conveys 
the  urine  to  a  vessel  at  a  lower  level  than  the  bladder,  the  free  end  of  the  tube 
being  submerged  in  an  antiseptic  solution.  A  light  gauze  dressing  and  a  T- 
bandage  complete  the  toilet  of  the  wound,  drainage  being  continued  until  the 
urine  is  clear,  usually  from  three  to  eight  days.  The  catheter  is  changed  every 
second  day;  the  bladder  is  irrigated  twice  daily,  and  each  time  this  is  done  the 
gauze  dressing  is  changed. 


SURGERY  OF  THE  BLADDER  533 

Should  there  not  have  been  cystitis  nor  continued  oozing,  tube  drainage  is 
unnecessary;  if  hemorrhage  does  not  require  packing  of  the  wound,  a  pad  of 
iodoform  gauze  is  loosely  applied  to  the  perineum,  care  being  taken  that  it  does 
not  prevent  the  free  escape  of  the  urine  from  the  wound.  This  escape  continues 
for  several  days,  and  then  stops  for  a  day  or  two,  owing  to  inflammatory  swell- 
ing, then  is  again  noticed,  but  becomes  less  marked  till  it  ceases  on  final  closure 
of  the  deep  wound. 

The  patient  should  keep  to  his  bed  not  longer  than  three  days;  suitable 
absorbent  material  (pillows  of  oakum  enclosed  in  one  layer  of  gauze,  and  fre- 
quently changed)  should  be  placed  so  that  it  will  catch  the  urine,  and  his 
thighs  and  buttocks  protected  from  irritation  by  the  urine  by  alcohol  baths, 
followed  by  applications  of  thick  zinc  ointment,  boric  ointment,  or  carbolated 
petrolatum. 

Immediate  suture  of  the  perineal  incision  is  attended  with  risk,  owing  to  the 
fact  that  the  deeper  portion  of  the  wound,  being  more  or  less  bruised  by  instru- 
ments, may  slough,  and  in  the  absence  of  drainage  cause  cellulitis.  If  the 
wound  is  allowed  to  remain  open  and  heal  slowly,  granulation  proceeds  from 
the  bottom  surfaceward. 

Sitting  and  walking  are  indicated  as  soon  as  the  patient's  general  con- 
dition and  perineal  soreness  permit;  the  sooner  the  better. 

Median  Lithotomy. —  In  this  operation  the  line  of  incision  follows  the 
raphe  between  the  scrotum  and  the  anus.  The  patient  being  in  the  same 
position  as  for  lateral  lithotomy,  a  staff  grooved  on  its  under  surface  is  intro- 
duced and  held  with  its  shaft  at  right  angles  to  the  plane  of  the  body,  its 
curve  hooked  up  under  the  symphysis  pubis.  The  point  of  the  knife — ^prefer- 
ably a  narrow  straight  bistoury — is  inserted  at  the  perineal  centre  just  posterior 
to  the  bulb  of  the  urethra,  and  pushed  on  until  its  point  engages  the  groove 
of  the  staff  at  the  membranous  urethra,  where  an  incision  is  made  about  an 
inch  in  length. 

The  surgeon  introduces  his  left  forefinger  into  the  wound  and  carries  it 
through  the  prostatic  urethra  into  the  bladder,  the  staff  being  withdrawn  when 
the  tip  of  the  finger  engages  the  vesical  orifice,  and  it  is  realized  that  the 
resistance  at  this  point  may  be  overcome  by  pressure.  In  cases  of  sphincteric 
sclerosis  and  contracture  a  blunt-ended  bistoury  is  passed  along  the  groove  of 
the  staff  and  the  sphincter  is  freely  divided,  after  which  the  finger  will  enter 
without  difficulty.  Thereafter  forceps  are  passed.  The  incision  divides  the 
skin,  the  superficial  fascia,  some  fibres  of  the  sphincter  ani,  the  lower  edge  of 
the  triangular  ligament,  the  compressor  urethras,  the  membranous  urethra,  and 
the  apex  of  the  prostate.    No  vessels  of  any  size  are  encountered. 

The  advantages  claimed  for  this  operation  are  that  there  is  no  risk  of 
injury  to  the  ejaculatory  ducts,  and  that,  no  arteries  of  any  size  being  divided, 
the  hemorrhage  is  slight.  There  is  some  risk,  however,  of  wounding  the  bulb 
of  the  urethra,  or  the  rectum  if  the  cut  be  carried  too  far  backward. 

Dolbeau  modified  the  median  operation  by  introducing  a  lithotrite  through 
the  wound,  crushing  the  stone,  and  washing  out  the  fragments  at  one  sitting. 
Owing  to  the  development  of  litholapaxy,  his  operation  "has  fallen  into  disuse. 

Bilateral  Lithotomy. — This  operation,  involving  the  use  of  a  special  instru- 


534 


GENITO-URINARY  SURGERY 


ment,  Dupuytren's  curved  double  lithotome  cache,  makes  a  large  opening 
by  cutting  from  within  out  both  prostatic  lobes.  The  approach  to  the  mem- 
branous urethra,  through  which  the  closed  cutting  instrument  is  introduced,  is 
by  a  crescentic  incision  across  the  perineum. 

The  sequelae  of  lithotomy  are  much  the  same  as  those  of  lithotrity;  there 
is  greater  likelihood  of  troublesome  hemorrhages  from  the  prostatic  plexus,  and 
of  infiltration  and  cellulitis  of  the  pelvic  cellular  tissues,  because  of  the  incision 
carried  through  the  prostate.  Shock,  collapse,  urinary  fever,  thrombosis  of  the 
pelvic  veins,  septicaemia,  pyaemia,  ■  and  peritonitis  have  all  been  recorded  as 
following  perineal  lithotomy. 

As  remote  sequelae,  vesico-rectal  or  urethro-rectal  fistulae,  vesical  or  urethral 
fistulae,  and  impotence  and  sterility  are  possible.    Though  it  would  seem  difficult 


Fig.  268. — Vesical  calculus  almost  completely  filling  an  hypertrophied  bladder. 

to  wound  and  obliterate  both  ejaculatory  ducts  in  the  operation  of  lateral 
lithotomy,  there  is  ample  clinical  evidence  that  this  sometimes  occurs. 

Perineal  lithotomy  would  seem  to  be  especially  indicated  for  the  removal 
of  small  or  medium-sized  stones  (one  inch  in  diameter)  .from  the  fairly  normal 
bladder  of  a  fat  man  with  average  perineal  depth,  provided  the  surgeon  is 
not  used  to  handling  crushing  instruments.  The  median  or  lateral  operation 
should  be  chosen  in  accordance  for  the  need  for  room. 

Suprapubic  Lithotomy. — Pierre  Franco  in  1561  is  credited  as  having  been 
the  first  to  extract  a  calculus  through  an  opening  above  the  pubis.  He  deemed 
the  operation  too  dangerous  to  be  repeated,  and  performed  it  only  as  a  last 
resort.  The  first  to  perform  it  in  this  country — according  to  Agnew — was 
Professor  Gibson,  of  the  University  of  Pennsylvania.  Unfortunately,  the  patient 
died  from  peritonitis. 


SURGERY  OF  THE  BLADDER  535 

At  the  present  day  this  approach  is  the  usual  one  for  the  removal  of  stones, 
litholapaxy  and  perineal  lithotomy  having  been  laid  aside  to  be  rediscovered  and 
adopted  with  fresh  enthusiasm  at  a  later  date. 

In  preparing  for  operation  the  suprapubic  and  perineal  regions,  the  penis, 
scrotum,  and  urethra  should  be  thoroughly  cleansed  as  for  any  formal  surgical 
procedure.    The  rectum  is  emptied  by  an  enema  just  before  the  operation. 

Local  or  general  anaesthesia  may  be  used.  The  patient  is  placed  fiat  upon 
his  back,  with  the  pelvis  and  shoulders  slightly  raised  to  relax  the  abdominal 
muscles.  The  operating-table  should  be  so  arranged  that  the  patient  can  in 
a  moment  be  placed  in  the  Trendelenburg  position,  should  this  be  required. 
The  varying  relations  of  the  peritoneum  to  the  parietes  of  the  hypogastric 
region,  in  accordance  with  vesical  distention,  have  been  already  noted.  Dis- 
tention of  the  bladder  rolls  back  the  loosely  attached  peritoneum  and  exposes 
considerable  bladder-wall  not  covered  by  that  membrane.  Distending  the 
rectum  elevates  the  posterior  portion  of  the  bladder  (Fig.  269).  The  device  for 
increasing  the  peritoneo-pubic  space  by  distention  of  both  bladder  and  the 
rectum  is  known  as  the  "  Garson-Petersen  method,"  and  by  it  this  space  is 
increased  to  its  utmost  extent. 

For  the  distention  of  the  rectum  a  dilatable  rubber  bag, — "  Petersen's  rectal 
colpeurynter," — collapsed  and  well  oiled,  is  introduced  into  the  rectum  above 
the  sphincters.  The  rectal  bag  is  dilated  to  the  required  extent;  usually  eight 
ounces  of  fluid  are  forced  in.  A  quantity  greater  than  this  may  injure  the 
rectum.  There  have  been  so  many  reported  cases  of  rectal  rupture  following 
the  use  of  the  colpeurynter  that  most  surgeons  absolutely  reject  this  appliance, 
holding  that  moderate  injection  of  the  bladder  and  elevation  of  the  pelvis  will 
give  the  desired  room.  The  bladder  is  thoroughly  washed  through  a  catheter, 
and  is  distended  with  eight  to  twelve  ounces  of  a  mild  antiseptic  solution  ( 1  to 
4000  protargol)  by  means  of  a  graduated  fountain  or  large  metal  syringe.  This, 
without  the  rectal  bag,  gives  ample  room. 

In  children  the  amounts  injected  depend  on  the  age  of  the  patient.  Four 
ounces  are  enough,  since  in  early  life  the  bladder  is  an  abdominal  rather  than  a 
pelvic  organ. 

The  bladder  having  been  distended,  a  three-inch  midline  incision  is  made 
running  down  to  the  pubic  symphysis,  passing  between  the  recti  and  pyramidales 
muscles,  dividing  the  sheath  of  the  rectus  and  the  layer  of  transversalis  fascia 
which  bounds  the  prevesical  space  anteriorly;  the  posterior  layer  of  this  fascia 
should  prevent  the  peritoneum  from  being  seen.  The  prevesical  fat  is  gauze- 
packed  upward  and  backward,  carrying  the  peritoneum  with  it,  and  then  well 
above  the  pubis  is  cleanly  cut  through  to  the  bladder- wall,  ligation  of  one  or 
more  veins  being  often  needful;  this  exposure  of  the  bladder  is  made  as  high 
as  practicable,  the  peritoneum  being  sutured  immediately  should  it  be  opened. 
Tearing  or  bruising  of  the  prevesical  fibro-adipose  tissue  favors  sloughing.  This 
complication  is  usual  and  apparently  unavoidable,  and  is  probably  the  reason 
for  the  higher  mortality  of  suprapubic  as  opposed  to  perineal  operation.  The 
bladder-wall,  having  been  clearly  exposed,  is  hooked  up  by  a  tenaculum, 
drawn  toward  the  surface  as  far  as  practicable,  and  an  incision  is  made  large 
enough  to  admit  the  index  finger.    Through  each  border  of  the  bladder-opening 


536 


GENITO-URINARY  SURGERY 


G    .- 

^  B 

.S3    S 


5   :- 


(?:     -.;cq      "^ 


fa 


SURGERY  OF  THE  BLADDER 


537 


a  thread  is  passed,  by  means  of  which  the  wound  can  be  held  forward  and  kept 
open.  Should  it  be  necessary  to  enlarge  the  opening,  this  may  be  done  with 
scissors.  As  the  bladder  empties,  the  opening  in  it,  if  properly  placed  high, 
can  be  drawn  completely  through  the  parietal  wound,  thus  protecting  the 
fibro-fatty  tissue  of  the  prevesical  space  from  infection  and  trauma.  By 
placing  the  patient  in  the  Trendelenburg  position  and  using  an  electric  light  the 
entire  bladder,  including  the  vesical  opening  of  the  urethra,  can  be  inspected  in 
patients  who  are  not  unduly  fat.  The  calculus  is  removed  by  the  scoop  or 
forceps;  if  it  is  encysted,  it  should  be  shelled  out  with  extreme  gentleness,  the 
opening  into  the  bladder  from  the  diverticulum  being  nicked  and  stretched 


Fig.  270. — Method  of  bladder  closure. 

should  this  be  necessary.  After  removing  the  major  calculus,  search  should 
be  made  for  any  remaining  calculi  or  fragments.  Some  stones  are  so  large 
that  the  parietal  incision  may  be  too  small  for  their  delivery  (Fig.  268);  a 
transverse  cut  through  the  sheaths  of  the  recti  may  be  needful  before  these 
muscles  can  be  sufficiently  retracted  to  give  the  required  room. 

The  condition  of  the  prostate  should  be  noted;  the  internal  vesical  sphincter 
should  be  stretched  by  the  insertion  of  the  index-finger  to  the  first  joint,  or 
cut  and  stretched  in  case  of  fibrosis,  or  the  prostate  should  be  removed  if  this 
be  indicated. 

After-Treatment  of  Suprapubic  Lithotomy  Cases. — The  after-treatment 
of  the  bladder,  the  stone  having  been  removed,  depends  upon  the  condition 


538 


GENITO-URINARY  SURGERY 


of  its  walls.    Provided  these  are  in  a  fairly  healthy  condition,  immediate  suture 
of  the  bladder-wound  is  indicated. 

When  the  bladder  wound  is  to  be  closed,  a  double  tier  of  sutures  should 
be  inserted.  The  first  of  these  is  an  over-and-over  stitch  of  the  musculature 
of  the  walls.  The  mucous  membrane  is  not  included  in  the  suture,  dependence 
being  placed  upon  the  muscular  approximation  to  bring  the  margins  of  the 
mucosa  together.  The  second  tier  is  also  placed  in  the  muscular  coat,  and  is 
of  the  Lembert  type,  either  interrupted  or  continuous  (Fig.  270).  To  deter- 
mine whether  or  not  the  lines  of  suture  are  tight  enough,  the  bladder  is  moder- 

A 


Fig.  271. — Gibson's  method  of  closing  the  bladder. 

ately  distended  with  a  mild  antiseptic  solution,  while  the  line  of  suture  is 
watched  for  leakage.  The  prevesical  space  should  always  be  drained  for  forty- 
eight  hours,  preferably  with  a  small  rubber-covered  wicK. 

After  bladder  suture  continuous  catheterization  is  indicated  for  from  three 
to  five  days,  supplemented  by  irrigation  twice  daily,  this  including  also  the 
urethra,  accomplished  by  drawing  out  the  catheter  till  the  injected  fluid  appears 
at  the  meatus. 

In  the  majority  of  cases  it  is  a  better  plan  to  drain  the  bladder,  and  this 
is  essential  should  there  be  marked  cystitis  or  should  the  bladder-walls  be  in  an 
unhealthy  condition.     The  drainage  may  be  kept  up  for  a  few  days  or  for 


SURGERY  OF  THE  BLADDER 


539 


several  weeks,  according  to  the  conditions  for  which  it  is  instituted.  For  satis- 
factory drainage  a  rather  large  tube  (30  to  40  F.)  should  be  used.  It  should 
have  two  fenestras  near  its  end,  and  should  extend  into  the  bladder  for  one 
inch.  The  bladder  wound  should  be  closed  above  and  below  the  tube  by  one 
or  two  layers  of  sutures,  inserted  as  previously  described  (Figs.  271  and  272). 
The  tube  from  the  bladder  should  lead  to  a  receptacle  placed  at  a  lower  level, 
which  should  contain  sufficient  antiseptic  fluid  (phenol  or  formaldehyde)  to 
cover  the  end  of  the  tube.  Dawbarn's  method  of  suction  drainage  is  illus- 
trated in  Fig.  273.    Its  use  necessitates  the  patient's  remaining  continuously  on 


I 

^ 

. 

'^ 

Fig.  272. — Gibson's  method  of  closing  the  bladder. 

his  back,  and  as  the  apparatus  is  prone  to  become  disarranged,  with  consequent 
wetting  of  the  patient,  and  requires  constant  attention  to  keep  the  reservoir 
supplied,  its  field  of  usefulness  is  not  a  large  one. 

The  drainage-tube  having  been  placed  and  the  vesical  wound  having  been 
closed  about  it  by  catgut  sutures  sufficiently  close  to  make  a  water-tight  junc- 
tion, as  tested  by  distention,  the  prevesical  space  is  carefully  dried  and  drained 
with  a  rubber-covered  gauze  wick.  The  upper  part  of  the  abdominal  incision 
is  closed  by  a  buried  catgut  suture  through  the  fascia  and  muscles  and  an 
interrupted  suture  in  the  skin.  The  bladder  should  be  irrigated  twice 
daily,  either  through  the  tube  or  through  the  urethra,  by  means  of  a  short, 


540 


GENITO-URINARY  SURGERY 


conical  metal  nozzle.  When  the  tube  is  removed,  or  should  it  drain  imper- 
fectly, the  skin  of  the  lower  abdomen  is  covered  with  a  thick  paste  of  boric 
or  zinc  ointment.     A  large  sterile  absorbing  dressing  of  gauze  and  cotton  is 

applied  to  the  hypogastric  region,  and 
an  oakum  pad  is  placed  beneath  the 
patient's  buttocks. 

Complications  and  Sequelcc  of  Supra- 
pubic Cystotomy. — During  operation  there 
may  be  troublesome  hemorrhage  from  the 
large  veins  in  the  perivesical  tissue;  these 
are  readily  secured  by  haemostatic  forceps. 
The  bladder-wall  may  bleed  freely  and 
persistently,  requiring  the  apphcation  of 
several  ligatures. 

The  peritoneum  may  be  opened;  this 
usually  occurs  before  the  bladder  has  been 
punctured  and  while  the  wound  is  still 
sterile.  The  opening  should  be  closed  at 
once  by  a  fine  catgut  suture. 

Shortly  following  suprapubic  cystotomy, 
the  complications  common  to  all  operations 
on  the  urinary  tract  may  develop — i.e., 
shock,  collapse,  suppression  of  urine,  cellu- 
litis, septicaemia,  pyaemia,  etc. 

Prevesical  infection  is  a  common,  often 
a  fatal,  sequel.  It  develops  in  from  three 
to  five  days,  sometimes  with  evident  symp- 
toms of  inflammation — i.e.,  local  tumor, 
pain  and  tenderness,  and  general  sepsis. 
Usually  the  onset  of  this  complication  is 
insidious,  the  condition  of  the  patient  sug- 
gesting uraemia  rather  than  suppuration; 
local  symptoms  are  but  slightly  marked,  or 
are  completely  absent,  and  the  tempera- 
ture is  normal  or  subnormal. 

When  prevesical  sloughing  and  advanc- 
ing perivesical  cellulitis  are  suspected,  the 
suprapubic  wound  should  be  opened  freely, 
and  the  space  in  front  of  the  bladder 
thoroughly  explored  and  drained. 
The  suprapubic  wound  may  refuse  to  close,  leaving  a  fistula.  This  rarely 
happens  unless  there  is  obstruction  to  the  flow  of  urine  through  the  urethra  or 
the  suprapubic  wound  becomes  tuberculous.  The  treatment  is  that  generally 
applicable  to  vesical  fistulae:  urethral  obstruction  is  removed,  the  bladder  is 
subjected  to  permanent  catheterization,  and  the  fistulous  opening  is  cauterized 
or  excised  and  the  vesical  opening  closed  by  suture. 

Hernia  sometimes  follows  suprapubic  cystotomy,  the  cicatrix  of  the  parietal 


Fig.  273. — Dawbarn's  method  of  supra- 
pubic bladder  drainage.  Water  from  the 
reservoir  (a  bucket  with  siphon  is  better 
than  the  ba?  illustrated)  flows  down  drop 
by  drop  till  it  fills  the  trap  B,  consisting  of 
a  loosely  tied  knot  in  a  piece  of  26  F.  rubber 
tubing.  The  trap  then  empties  itself,  mak- 
ing suction  on  the  side  tube  AFC.  _  The 
small  tube  C,  not  larger  than  16  F.,  is  in- 
serted into  the  patient's  bladder  inside  a 
larger  rubber  tube,  so  that  there  is  an  air 
space  between  the  two.  The  urine  is  col- 
lected in  the  bottle  E.  All  connections 
must  be  air-tight. 


SURGERY  OF  THE  BLADDER  541 

incision  yielding  to  intra-abdominal  pressure.  A  transverse  cut  dividing  the 
attachment  of  the  recti  muscles  is  much  more  liable  to  be  followed  by  this 
complication  than  is  the  ordinary  vertical  incision.  It  is  treated  by  a  truss  or 
by  radical  operation. 

When  the  bladder  is  sutured  by  silk  threads,  these  by  escaping  into  the 
vesical  cavity  may  form  foci  for  new  calculus-formations. 

Treatment   of  Vesical   Calculi  in  Women 

If  the  stone  is  quite  small,  the  urethra  may  be  dilated  to  the  required  extent, 
first  by  suitable  dilators,  then  by  the  little  finger.  This  being  done  slowly,  there 
will  be  but  little  laceration  of  the  mucous  membrane,  and  the  incontinence  that 
follows  will  be  of  short  duration.  The  stone  may  be  extracted  by  means  of  a 
scoop  or  forceps.  If  the  stone  is  too  large  to  be  removed  intact,  it  may  be 
crushed  and  washed  out  in  the  usual  manner.  If  too  large  and  too  hard  to  be 
removed  in  this  way,  or  if  the  bladder  requires  drainage,  vaginal  or  suprapubic 
lithotomy  is  indicated,  but  this  is  rarely  necessary.  Incision  of  the  urethra 
and  neck  of  the  bladder  should  never  be  employed  on  account  of  the  risk 
of  permanent  incontinence. 

Kelly  thus  performs  the  vaginal  operation:  The  patient  is  placed  in  the 
knee-chest  posture ;  a  catheter  in  the  bladder,  or  speculum  in  the  urethra  allows 
air  distention  of  the  viscus.  The  posterior  vaginal  wall  is  lifted  well  upward 
towards  the  sacrum  by  means  of  a  Sims's  speculum,  and  the  anterior  vaginal 
wall  is  brought  into  view.  An  incision  into  the  bladder  is  made  through  the 
vesicovaginal  septum.  The  slight  hemorrhage  passes  into  the  bladder,  and  thus 
the  field  of  operation  is  kept  clear.  A  stone  in  the  bladder  or  lower  portion  of 
the  ureter  may  be  easily  removed  by  forceps  or  a  scoop. 

FOREIGN  BODIES  IN  THE  BLADDER 

In  addition  to  calculi  there  has  been  found  in  the  bladder  an  almost  unlimited 
variety  of  foreign  bodies,  such  as  fragments  of  catheter,  hair-pins,  pipe-stems, 
lamp-wicks,  pencils,  spicules  of  bone,  bullets,  shot,  etc.  (Figs.  274,  275,  and 
276).  These  may  enter  the  bladder  by  way  of  the  urethra,  may  be  driven  into 
the  viscus  by  direct  violence,  or  may  gain  access  by  a  process  of  ulceration. 


Fig.  274. — Le  Fur's  case  of  foreign  body  in  bladder,  diagnosed  and  removed  by 
cystoscopy.  Silk  suture  12  inches  long.  The  knotted  end  A,  B,  black  in  color,  projected 
into  the  bladder;  the  other,  B,  C,  was  located  in  a  prevesical  cavity,  and  represents  the  peri- 
toneal suture  of  an  hysterectomy. 

Portions  of  catheter  are  more  frequently  found  in  the  bladder  than  any  other 
foreign  body.  The  breaking  of  a  soft  instrument  in  the  urethra  or  bladder 
usually  occurs  when  patients  catheterize  themselves.  Either  from  ignorance 
or  from  carelessness,  they  continue  to  use  a  catheter  after  it  has  become  weak 
and  brittle. 

The  mechanism  bv  which  foreign  bodies  introduced  into  the  meatus  reach 


542  GENITO-URINARY  SURGERY 

the  bladder  has  been  described  in  considering  foreign  bodies  in  the  urethra. 
Often  the  introduction  of  these  bodies  is  suggested  by  a  form  of  sexual  perver- 
sion. Sometimes  they  are  passed  in  for  the  purpose  of  allaying  the  intolerable 
itching  and  burning  which  are  symptomatic  of  posterior  urethritis  and  are 
referred  to  the  urethra  just  behind  the  meatus. 

Foreign  bodies  driven  in  by  force  may  be  pieces  of  bone,  bullets,  shot^ 
fragments  of  clothing,  sometimes  splinters  of  wood.  Foreign  bodies  which  enter 
the  bladder  by  the  process  of  ulceration  are  fragments  of  bone  and  the  contents 
of  the  intestinal  canal.  Dermoid  cysts  and  extra-uterine  pregnancies  sometimes 
discharge  into  the  bladder.  Morris  says,  ''Among  surgical  catastrophies  and 
miraculous  recoveries  is  the  case  of  a  pair  of  pressure  forceps  left  in  the  peri- 
toneal cavity  at  an  ovariotomy,  in  which  ulceration  of  the  vesical  wall  occurred 


Fig.   275. — Shoestring  incrusted  with  Fig.  276. — Hair  pin. 

phosphates. 

and  the  forceps  entered  the  bladder  and  were  then  successfully  removed  after 
a  long  interval."  Morris  quotes  Guyon  and  Henriet  to  the  effect  that  a  foreign 
body  once  fairly  within  the  cavity  of  the  bladder  will  usually  occupy  a  transverse 
position  between  the  summit  and  the  neck  and  rather  nearer  the  neck.  In  the 
empty  bladder  this  is  the  only  position  which  bodies  not  longer  than  four  inches 
can  take.  A  body  five  inches  long  assumes  either  a  vertical  or  an  oblique 
position. 

Symptoms.— As  in  the  case  of  stone,  foreign  bodies  in  the  bladder  may 
remain  quiescent  for  a  long  period.  Commonly  they  produce  frequent  urination, 
tenesmus  and  pain,  haematuria,  and,  sooner  or  later,  cystitis.  If  from  their 
shape  they  exert  constant  pressure  in  one  portion  of  the  bladder,  ulceration  and 
perforation  take  place,  with  either  the  formation  of  a  limited  abscess  opening 
externally  or  into  one  of  the  neighboring  viscera,  or  diffuse  cellulitis. 

Unless  the  body  is  expelled  shortly  after  it  is  introduced,  or  is  of  such  a 
nature  as  to  be  slowly  disintegrated,  there  is  no  tendency  toward  spontaneous 
evacuation  through  the  urethra.  It  soon  becomes  incrusted  with  urinary  salts 
and  grows  progressively  larger. 

Diagnosis.— There  is  nothing  in  the  symptomatology  of  a  foreign  body 


SURGERY  OF  THE  BLADDER  543 

to  distinguish  it  from  stone.  Frequently  careful  questioning  will  elicit  a  history 
of  a  catheter  having  been  broken  in  the  bladder,  or  of  a  body  which  has  been 
introduced  into  the  urethra  having  disappeared,  or  of  a  traumatism,  such  as 
gunshot  wound  in  the  vesical  region.  In  the  absence  of  such  history,  the 
diagnosis  is  sometimes  possible  after  exploration  with  a  vesical  sound  and 
bimanual  palpation.  Thus  could  be  felt  a  portion  of  umbrella  rib  or  slate- 
pencil,  for  instance.  The  most  reliable  means  of  diagnosis  is  cystoscopic 
examination.  This  will  determine  the  shape,  nature,  and  position  of  the  foreign 
body,  and  will  enable  the  surgeon  to  select  the  safest  and  most  efficient  methods 
of  removing  it  from  the  bladder. 

When  first  inserted,  foreign  bodies  are  comparatively  easy  to  extract,  since 
there  is  then  no  cystitis  and  little  incrustation  has  taken  place.  These  cases, 
however,  rarely  present  themselves  for  treatment  until  cystitis  has  reached  such 
a  stage  as  to  cause  almost  unbearable  suffering.  The  body  is  then  thickly  crusted 
with  urinary  salts. 

Treatment. — If  the  history  of  the  case  indicates  or  if  cystoscopic  examina- 


FlG.  2  77. — Hook  for  the  extraction  of  hair-pins  from  the  female  bladder. 

tion  shows  that  the  bladder  contains  a  portion  of  a  catheter,  it  is  permissible 
to  attempt  first  to  free  it  of  its  incrustation  by  the  gentle  use  of  Young's  cysto- 
scopic rongeur,  and  afterwards  to  grasp  it  in  the  jaws  of  this  instrument  and 
remove  it. 

Foreign  bodies,  such  as  seeds,  shot, -and  pieces  of  twigs  or  leaves,  may  be 
removed  by  the  tube  and  evacuator  employed  in  litholapaxy.  If  the  body  is 
of  such  shape  or  size  that  it  cannot  be  taken  out  through  the  urethra,  cystotomy 
is  indicated.  Before  the  advent  of  cystitis,  either  the  suprapubic  or  the  perineal 
route  may  be  chosen.  If  the  foreign  body  is  of  large  size  or  irregular  in  shape, 
or  both,  the  former  route  is  to  be  preferred. 

When  the  bladder  is  infected,  or  if  the  foreign  body  is  of  such  size  that 
it  may  be  readily  removed  through  a  comparatively  small  opening,  the  perineal 
incision  is  the  safest.  The  after-treatment  is  that  applicable  to  perineal 
urethrotomy. 

In  women  the  greater  distensibility  of  the  urethra  makes  the  extraction  of 
foreign  bodies  much  easier.  Probably  hair-pins  are  more  frequently  found  than 
any  other  foreign  body.  A  special  instrument  is  used  by  French  surgeons  for 
their  extraction  (see  Fig.  277). 


CHAPTER  XXIV 

SURGERY  OF  THE  BLADDER  (Continued) 

TUMORS 

Tumors  of  the  bladder  may  be  benign  or  malignant. 

Benign  tumors  are  the  papillomas,  the  adenomas,  the  fibromas,  the  myomas, 
the  myxomas,  the  angiomas,  and  cysts. 

The  malignant  growths  include  carcinomas,  sarcomas,  and  mixed  tumors. 
Carcinomas  may  be  squamous  or  glandular.  The  sarcomas  may  be  round-celled, 
spindle-celled,  melanotic,  or  mixed,  as  fibrosarcoma,  lymphosarcoma,  and  myxo- 
sarcoma.    (Fig.  278.) 

Of  all  bladder-growths,  more  than  half  are  malignant,  carcinoma  being 
found  more  frequently  than  all  other  bladder-tumors  combined. 

Of  structurally  benign  growths,  papilloma  is  commonest.  Next  in  order 
comes  the  myxoma,  or  bladder  polyp;  adenoma,  myoma,  angioma,  and  fibroma 
are  rare. 

The  seat  of  bladder-tumors  is  usually  about  the  base,  in  the  region  of  the 
trigonum.  Exceptionally,  when  single,  these  growths  are  found  involving  the 
upper  two-thirds  of  the  bladder-walls.  The  mode  of  attachment  of  the  tumor 
to  the  bladder-wall  varies  in  different  cases.  Sometimes  it  is  attached  by  a 
long  slender  pedicle;  or  the  pedicle  may  be  broad,  and  there  may  be  infiltra- 
tion of  the  surrounding  bladder-tissues;  or  there  may  be  no  pedicle;  or  the 
entire  thickness  of  the  bladder  may  be  involved,  the  infiltration  extending  be- 
yond the  area  apparently  diseased.  Men  are  more  frequently  affected  with 
bladder-tumor  than  are  women.  The  tumors  may  develop  at  any  age,  but  are 
commonest  between  the  fortieth  and  the  sixtieth  year. 

The  great  frequency  of  bladder-tumors  in  anilin  workers  has  been  pointed 
out  by  Rehn,  twenty-one  cases  having  come  under  his  observation.  Of  these, 
three  were  benign  and  eighteen  malignant.  The  patients  had  been  employed 
in  a  factory  from  five  to  twenty-nine  years. 

Albarran  states  that  vesical  tumors  are  multiple  in  twenty-five  per  cent,  of 
cases.  Small,  single,  well-pedicled  tumors  are  likely  to  be  macroscopically 
benign;  large,  infiltrating,  sessile  tumors  are  commonly  malignant. 

Papilloma. — Papillary  tumors  are  multiple  in  about  forty  per  cent,  of  all 
cases.  (Fig.  279.)  They  may  be  pedunculated  or  sessile  and  vary  from  the 
size  of  a  pea  to  that  of  an  orange.  They  may  form  a  villous  surface,  made  up 
of  closely  grouped  fine  papillae  springing  from  the  mucous  membrane,  or  may 
appear  in  the  form  of  a  cauliflower  growth,  each  of  the  papillae  sending  out 
offshoots;  in  the  latter  case  they  usually  rise  from  a  comparatively  small  stalk. 
It  must  be  borne  in  mind  that  all  tumors  of  the  bladder  may  be  covered  by  a 
villous  surface.  In  the  true  papillomata.  however,  the  tumor  is  composed  en- 
tirely of  papillae.  (Fig.  280.)  Each  papilla  is  made  up  of  a  central  capillary 
loop,  together  with  a  stroma  of  delicate  fibrous  tissue,  covered  with  layers  of 
544 


Fig.  278. — Myxosarcoma.     (Albarran.) 


546 


GENITO-URINARY  SURGERY 


cylindrical  epithelium  corresponding  in  type  with  the  normal  vesical  epithelial 
cells.  These  papillae  are  planted  upon  a  nbro-muscular  base;  the  whole  mass  may 
be  sessile,  covering  a  comparatively  large  area,  or  may  be  pedunculated,  the  stem 
sometimes  being  half  an  inch  in  diameter.  In  some  cases  papillomata  form  com- 
pact masses  with  villi  of  only  moderate  length. 

Transitional  forms  are  found  in  which  the  histological  structure  of  the  cells 
(changes  in  the  shape,  staining  properties,  arid  nuclei  of  the  epithelial  elements) 
shows  that  these  tumors  may  be  transformed  into  epitheliomata. 


Vi    / 


Fig.     279. — Multiple  papillomata.     (Albarran.) 


A  necrotic  condition  of  the  villi,  an  oedematous  condition  of  the  surrounding 
mucosa,  or  nodules  i;i  this  membrane,  failure  of  the  slough  caused  by  high- 
frequency  treatment  to  separate  promptly,  and  the  deposition  of  lime  salts  on  the 
tumor  following  such  treatment,  together  with  the  presence  of  palpable  indura- 
tion when  the  posterior  wall  is  affected,  are  significant  of  malignant  change 
(Geraghty). 

Villous  tumors  are  prone  to  bleed  from  partial  strangulation  of  their  blood- 
supply  incident  to  muscular  contraction,  and  from  the  fact  that  the  delicate^ 


SURGERY  OF  THE  BLADDER 


547 


loosely  floating  papillae  are  likely  to  become  detached.  These  may  be  encrusted 
with  urinary  salts. 

While  the  papillomas  are  here  considered  as  benign  tumors,  they  are  so 
only  from  the  standpoint  of  the  pathologist;  to  the  clinician  they  are  potentially 
or  actively  malignant,  for  not  only  are  they  prone  to  develop  malignant  changes, 
but  after  removal  there  is  a  tendency  to  recurrence,  both  locally  and  in  other 
parts  of  the  bladder,  probably  as  a  result  of  direct  transplantation.  Zuckerkandl 
reports  a  case  with  autopsy  in  which  the  bladder  and  ureter  were  literally  filled 
with  papillomata  which, had  arisen  from  a  mother-growth  in  the  kidney.  ' 

Myxoma. — ^This  tumor  is  much  rarer  than  papilloma.    It  is  most  frequently 


Fig.  280. — Papilloma  of  the  bladder.     (No.  4221.     From  the  Mutter 
Museum,  College  of  Physicians  of  Philadelphia.) 

encountered  in  childhood,  and  is  probably  in  some  cases  congenital.  The  m3rxo- 
mata  are  often  multiple  and  pedunculated,  and  are  much  like  similar  tumors 
found  in  the  nose.  Their  stroma  is  made  up  of  fibrous  and  mucous  tissue  well 
vascularized.  They  are  hard  or  soft  in  accordance  with  the  preponderance  of 
the  mucous  or  of  the  fibrous  tissue. 

When  multiple,  several  tumors  may  grow  from  a  single  pedicle;  this,  by 
elongating,  may  allow  the  tumors  to  slip  through  the  female  urethra  and  appear 
at  the  meatus.  The  mucous  membrane  about  the  attachment  of  the  pedicle  is 
not  infiltrated.  These  tumors  may  recur  even  after  a  seemingly  thorough 
removal. 

Fibroma. — Tumors  of  this  variety  in  the  bladder  are  excessively  rare.    They 


548 


GENITO-URINARY  SURGERY 


resemble  in  structure  fibromata  formed  elsewhere  in  the  body,  and  are  generally 
sessile;  they  grow  from  the  mesoblastic  structures  of  the  bladder,  and  are 
covered  with  unaltered  mucous  membrane  or  villi.  They  invariably  occur 
in  adults. 

Myoma. — Myomata  of  the  bladder  were  supposed  by  Virchow  to  be  merely 


Fig.  281. — Carcinoma  of  the  bladder.     (From  the  Museum  of  Pathology, 
University  of  Pennsylvania.) 

prostatic  outgrowths,  but  Belfield  has  demonstrated  that  there  may  be  myomata 
of  the  bladder  pure  and  simple.  They  are  seldom  pedunculated,  but  are  pro- 
truded from  the  muscular  coat,  often  appearing  on  the  outside  of  the  organ  as 
well  as  in  the  interior.  They  sometimes  attain  a  large  growth,  sufficient  to 
be  mistaken  for  a  uterine  fibroma,  and  are  extremely  vascular. 

Angioma. — This  is  an  infrequent  vesical  tumor,  but  it  is  not  so  rare  as  some 
of  the  solid  tumors  that  have  just  been  described.  The'  venous  variety, 
haemangioma,  as  viewed  cystoscopically,  appears  as  a  characteristic  bluish  mass. 


SURGERY  OF  THE  BLADDER  549 

They  occur  in  or  about  the  ureteral  orifice,  as  a  rule,  but  may  be  present  else- 
where in  the  mucosa.  They  may  undergo  sarcomatous  degeneration  and  may 
be  confounded  with  melanotic  sarcoma. 

Varicose  Veins  of  the  Bladder. — Aside  from  the  enormous  distention  of 
the  venous  plexus  around  the  bladder,  which  accompanies  prolonged  vesical 
tenesmus  and  enlarged  prostate,  there  have  been  observed  a  few  cases  of  true 
varicose  veins  of  this  viscus.  The  only  symptom  is  profuse  spontaneous  bleed- 
ing. The  diagnosis  must  be  made  by  cystoscopic  examination.  When  this  is 
positive,  and  the  hemorrhage  repeated  or  threatening,  the  veins  should  be  ligated, 
suprapubic  cystotomy  being  done. 

Sarcoma. — Tuffier  quotes  Fenwick,  who  has  collected  fifty  cases  of  vesical 
sarcoma,  as  saying  that  in  children  these  growths  are  often  multiple,  sessile  or 
subsessile,  generally  polypoid  in  form;  in  the  adult  they  are  more  often  single 
than  multiple,  and  are  pedunculated  in  only  ten  per  cent,  of  cases.  In  thirty- 
four  and  a  half  per  cent,  of  cases  they  are  of  the  round-celled  variety,  and  in 
almost  seventeen  per  cent,  spindle-celled.  They  attain  a  considerable  size, 
sometimes  that  of  a  foetal  head.  They  are  generally  composed  of  purely  sarco- 
matous elements,  yet  villous  papilloma  degenerating  into  sarcoma  has  been 
observed.  Sarcomata  are  usually  multiple.  They  commonly  grow  from  the 
neighborhood  of  the  ureteral  orifices,  or  from  the  mucous  membrane  lying  between 
these  openings.  In  women  infiltration  frequently  extends  along  the  urethra. 
From  its  rapid  growth,  sarcoma  is  likely  to  pass  beyond  the  limits  of  the 
bladder,  invading  the  pericystic  tissues  and  finally  the  bones  of  the  pelvis. 

Sarcomatous  degeneration  may  be  mixed,  giving  rise  to  such  forms  as  angio-, 
enchondro-,  and  lympho-sarcoma. 

Carcinoma. — This  may  appear  in  the  form  of  squamous  or  tubular  epi- 
theUoma  or  alveolar  cancer. 

Vesical  cancer  is  usually  sessile,  involves  the  whole  thickness  of  the  bladder- 
wall,  and  presents  an  uneven,  often  ulcerating,  surface  (Fig.  281);  it  is  hard 
on  palpation,  is  surrounded  by  peripheral  induration,  and  is  frequently  multiple. 
The  growth  is  extremely  slow.  Extensive  ulceration  is  rare.  Metastasis  may 
occur  very  early,  before  there  is  extensive  involvement  of  the  bladder-wall,  or 
not  till  the  growth  has  attained  large  proportions.  The  affection  occurs  most 
frequently  in  men,  and  between  the  fiftieth  and  the  sixtieth  years. 

At  times  the  growth  is  pedunculated,  suggesting  the  appearance  of  papilloma. 

On  intravesical  examination  these  growths  are  found  to  vary  greatly  in 
appearance.  They  may  form  irregularly  projecting  masses  covered  with  normal 
mucous  membrane,  or  they  may  appear  as  comparatively  flat  areas  of  indura- 
tion, the  surface  of  which  may  be  smooth  or  ulcerated.  In  some  cases  there  is 
bulk  sufficient  almost  entirely  to  fill  the  bladder;  very  frequently  the  surface  is 
covered  by  a  papillary  growth.  Infiltration  and  induration  are  the  most  char- 
acteristic features. 

When  by  rectal  examination  a  hardening  of  the  bladder-wall  can  be  felt,  this 
is  almost  pathognomonic  of  cancer. 

Although  extension  of  the  disease  to  the  iliac  and  abdominal  glands  and 
thence  to  the  abdominal  viscera  occurs,  extension  to  neighboring  organs  appears 
to  be  rare.     Watson  quotes  Barling  to  the  effect  that  in  only  three  out  of 


550  GENITO-URINARY  SURGERY 

fifteen  cases  of  carcinoma  of  the  bladder  did  such  extension  occur;  and  in  nine, 
in  the  same  series  of  cases,  secondary  deposits  were  found  in  other  organs. 
Of  forty-nine  cases,  thirty-three  had,  as  secondary  changes,  hydronephrosis  or 
pyonephrosis,  or  both. 

Cystic  Tumors  of  the  Bladder. — The  most  systematic  and  detailed  study 
of  these  rare  growths  is  found  in  Clado's  treatise  on  Tumors  of  the  Bladder. 
His  teaching  in  regard  to  them  may  be  outlined  as  follows: 

Cysts  are  of  epithelial  origin,  or  arise  from  foetal  inclusion  (dermoid  cysts) . 

Epithelial  cysts  are  equally  common  in  men  and  in  women,  are  observed 
during  any  period  of  life  except  in  early  infancy,  and  are  most  frequent  between 
the  thirtieth  and  fiftieth  years.  They  are  usually  placed  about  the  base  of  the 
bladder  in  the  region  of  the  vesical  neck,  probably  because  the  vesical  glands 
are  particularly  abundant  in  these  regions.  They  may  occupy  the  entire  vesical 
cavity,  and  sometimes  are  associated  with  cysts  of  the  kidney  pelvis.  Clini- 
cally, they  are  distinguished  according  to  size,  as  small  or  large. 

Small  cysts  appear  as  minute  or  medium-sized  vesicles  filled  with  clear 
fluid.  This  may  become  turbid  or  even  blood-stained.  They  may  be  due 
either  to  alteration  of  the  normal  vesical  glands  producing  cysts  of  retention,  or 
to  local  epithelial  proliferation,  followed  by  central  softening. 

Large  epithelial  cysts  show  a  tendency  to  become  enucleated  from  the  vesical 
wall  and  form  pedunculated  growths.  Vincent  records  a  case  in  a  child  between 
three  and  three  and  a  half  years  old  in  whom  the  pedicle  was  so  long  that  the 
cyst  passed  through  the  urethra  and  presented  in  the  vulva. 

Dermoid  cysts  may  invade  the  bladder  primarily  or  may  be  paravesical, 
communicating  with  the  bladder  by  an  orifice.  Over  forty  cases  have  been 
reported.  These  cysts  are  nearly  always  observed  in  women,  and  symptoms 
develop  between  adolescence  and  old  age.  The  tumor  is  usually  placed  at  the 
base  of  the  bladder.  Sometimes  it  appears  in  the  form  of  a  polyp ;  that  is,  it  is 
pedunculated.  These  cysts  always  contain  hair,  and  the  passage  of  this  in  the 
urine  constitutes  a  major  symptom.  Fragments  of  bone  and  teeth  are  also 
passed  at  times. 

Microscopically,  these  cysts  show  the  structure  of  skin,  containing  sebaceous 
glands  and  hair-follicles  in  a  state  of  physiological  activity.  Even  small  tumors 
may  discharge  comparatively  large  quantities  of  hair  for  a  long  time. 

Thirty-two  cases  of  paravesical  dermoid  cysts  have  been  collected  by 
Clado;  seven  originated  in  the  ovary,  seven  formed  paravesical  tumors;  in 
eighteen  the  only  symptom  recorded  was  micturition  of  hair. 

The  dermoid  cyst  usually  remains  latent  until  about  the  twenty-first  year, 
symptoms  of  the  tumor  becoming  manifest  between  this  and  the  fortieth  year. 
The  tumor  is  usually  placed  in  the  rectovesical  septum,  beneath  the  peritoneum. 
In  two  cases  it  was  placed  on  the  apex  of  the  bladder,  between  the  peritoneum 
and  the  vesical  wall.  Sometimes  these  cysts  reach  huge  dimensions,  extending 
above  the  umbilicus,  and  weighing  over  fourteen  pounds.  In  one  case,  owing 
to  pressure,  retention  developed.  Calculi  frequently  form,  having  for  their 
nuclei  masses  of  hair.  These  cysts  are  usually  complicated  by  cystitis  of  varying 
degrees  of  intensity. 

Symptoms  of  Tumor  of  the  Bladder. — The  benign  bladder-tumor  may 
exist  for  years  and  excite  no  symptoms. 


SURGERY  OF  THE  BLADDER  551 

Usually  hemorrhage  is  the  symptom  which  first  suggests  the  possibility  of 
a  bladder-growth.  The  characteristic  features  of  this  hemorrhage  are  its  occur- 
rence without  apparent  cause;  its  sudden  onset,  and  its  abrupt  cessation.  If 
the  bleeding  is  copious,  if  the  last  urine  passed  contains  more  blood  than  that 
first  evacuated,  if  the  blood  is  bright  red  in  color,  if  clots  are  passed,  and  if 
gentle  instrumentation  occasions  free  hemorrhage,  all  the  characteristic  features 
of  bleeding  from  bladder-tumor  will  be  present. 

This  bleeding  may  last  a  day,  or  may  continue  for  weeks,  may  be  so  slight 
as  to  excite  no  constitutional  symptoms,  or  may  be  severe.  Exceptionally,  as  a 
result  of  intravesical  bleeding,  dense  clots  so  obstruct  urination  that  immediate 
operation  is  necessary.  Frequent  recurrences  of  the  bleeding  may  exhaust  the 
patient,  and  may  finally  occasion  death.  It  must  be  borne  in  mind  that  the 
amount  of  bleeding  is  by  no  means  commensurate  with  the  size  of  the  tumor. 
At  times,  in  place  of  haematuria,  or  associated  with  it,  there  is  what  Ultzmann 
calls  fibrinuria — that  is,  in  place  of  pure  blood  the  albuminous  constituents 
of .  this  fluid  are  exuded  through  the  distended  vessels  in  the  region  of  the 
growth.    The  urine  when  passed  coagulates. 

Pain  usually  is  not  severe,  except  when  there  is  accompanying  cystitis.  It 
is  especially  marked  when  the  tumor  is  placed  in  the  region  of  the  vesical  neck, 
and  may  be  reflected  to  the  hypogastric  region,  the  anus,  the  testicle,  the  penis, 
or  dowTi  the  thighs.  It  is  most  marked  on  the  completion  of  urination  and 
when  the  bladder  is  invaded  by  a  malignant  growth.  Benign  tumors  often  cause 
no  pain. 

Frequent  urination  is  not  a  constant  symptom.  When  noted  it  is  not  aggra- 
vated by  exercise,  and  is  not  more  marked  at  night.  Pain  and  frequent  urina- 
tion are  constant  and  distressing  symptoms  when  the  bladder  has  become  in- 
fected; they  are  then  due  to  the  cystitis  rather  than  to  the  tumor. 

Tumors  in  close  relation  to  the  urethral  orifice  may  cause  partial  or  complete 
retention  by  mechanical  interference  with  the  outflow  of  the  fluid. 

The  passage  of  fragments  of  the  tumor  is  the  only  absolutely  conclusive 
sign  of  bladder- tumor,  aside  from  direct  examination.  A  microscopical  examina- 
tion is  necessary  to  determine  the  nature  of  the  fragments  passed,  since  coagu- 
lated fibrin  or  blood-clot  may  readily  be  mistaken  for  a  new  growth  when 
examined  macroscopically. 

Diagnosis. — This  is  founded  on  the  sudden,  apparently  causeless  free  bleed- 
ings recurring  with  increasing  frequency,  the  passage  of  tumor-fragments, 
examination  with  the  cystoscope,  combined  rectal  and  suprapubic  palpation  in 
the  case  of  malignant  growths,  and  exploratory  cystotomy.  Non-infiltrating 
growths  ca:nnot  be  detected  by  palpation. 

The  successive  appearance  of  single  symptoms  strongly  points  to  vesical 
tumor;  the  immediate  association  of  several  syn^ptoms  is  the  rule  in  cystitis. 
In  the  latter  the  appearance  of  pus  is  never  long  delayed;  in  tumors  it  is  often 
delayed.  In  tumors  that  infiltrate  the  bladder-wafl,  in  contradistinction  to 
pedunculated  neoplasms,  hemorrhage  may  be  a  late  symptom,  while,  on  the 
other  hand,  the  irritation  of  the  muscular  w^all  induces  frequent  urination  at 
an  earlier  period  than  in  tumors  with  pedicles.  Haematuria,  intermittent  or 
profuse  and  lasting  a  long  time  without  other  symptoms,  is  always  suggestive 


552  GENITO-URINARY  SURGERY 

of  vesical  tumor  rather  than  of  cystitis.  A  bladder  which  contains  a  tumor 
is  peculiarly  susceptible  to  infection. 

Prognosis. — Even  in  benign  tumors  the  outlook  of  a  case  allowed  to  run 
its  course  is  unfavorable.  Very  exceptionally  individual  polypoid  growths  are 
discharged  spontaneously.  As  a  rule,  the  growth  is  progressive.  Freyer  men- 
tions a  case  of  papilloma  existing  eighteen  years. 

From  mechanical  action  a  large  tumor  of  the  bladder  may  cause  displace- 
ment of  neighboring  organs,  pressure  upon  the  rectum,  or  partial  or  complete 
obliteration  of  the  ureters  or  the  urethra. 

The  patient  ultimately  perishes,  either  from  exhaustion  incident  to  hemor- 
rhage or  from  ascending  pyelonephritis.  The  course  of  these  cases  is  often 
extremely  slow. 

When  the  tumor  is  thoroughly  removed  the  prognosis  in  benign  cases  is 
good,  though  recurrence  may  take  place.  Even  in  malignant  growths  a  thorough 
removal  in  the  early  stages  may  accomplish  radical  cure. 

TREATMENT  OF  TUMORS  OF  THE  BLADDER 

The  diagnosis  having  been  established,  there  is  but  one  treatment  to  be 
seriously  considered — complete  removal  of  the  growth,  provided  the  nature  of 
the  tumor  permits  of  such  a  procedure.  The  benign  tumors  as  a  class  are  easily 
removable,  and,  as  many  of  them  are  prone  to  undergo  malignant  degeneration, 
their  destruction  is  important  not  only  on  account  of  the  symptoms  they  produce, 
but  also  as  a  prophylactic  measure.  The  removal  of  malignant  tumors  in  their 
earlier  stages  may  also  be  curative. 

The  palliative  treatment  of  tumors  of  the  bladder  is  confined  to  check- 
ing bleeding  and  relieving  pain.  This  treatment  may  be  required  because  of 
reluctance  on  the  part  of  the  patient  to  consent  to  operation;  more  frequently 
because  by  the  time  a  positive  diagnosis  of  tumor  is  made  infiltration  has 
already  extended  wide  of  the  bladder,  and  a  radical  operation  is  no  longer  pos- 
sible. The  treatment  of  haematuria  in  general  is  that  applicable  to  the  relief  of 
vesical  congestion.  The  most  potent  measure  for  the  checking  of  the  bleeding 
is  the  hypodermic  injection  of  normal  serum,  human  or  horse,  in  quantities  of 
from  10  to  50  c.c,  every  two  or  three  or  four  days,  according  to  the  result 
obtained.  Local  treatment  may  be  conducted  by  hot  injections  of  alum  four 
drachms  to  the  pint,  hydrastis  two  ounces  to  the  pint,  or  acetanilid  five  per 
cent,  solution,  or  adrenalin  solution  1  to  5000.  When  clots  are  present  and 
produce  retention,  they  should  be  aspirated  through  a  catheter,  cystoscope 
sheath,  or  Bigelow's  evacuating  tube.  If  bleeding  persists  in  spite  of  injections, 
or  if  these  produce  great  pain  and  seem  to  increase  hemorrhage,  permanent 
catheterization  is  indicated.  If  this  is  unsuccessful  because  the  catheter  becomes 
blocked  by  clots,  cystotomy,  should  be  performed,  with  cauterization  of  the 
tumor  and  the  insertion  of  a  large  tube.  Packing  the  bladder  full  of  iodoform 
gauze  about  a  drainage-tube  inserted  down  to  the  bladder  base  must  sometimes 
be  resorted  to. 

Pain  may  be  quieted  by  instillations  of  eucaine.  Usually  morphine  hypo- 
dermically  will  be  required  for  its  relief.  Cystitis  or  retention  should  be  treated 
in  accordance  with  the  directions  already  given, 


SURGERY   OF  THE  BLADDER 


553 


Hydrastis,  ergo  tin,  and  gallic  acid  given  in  moderate  doses  by  the  mouth 
can  at  least  do  no  harm. 

Curative  Treatment. — For  the  destruction  or  removal  of  vesical  tumors 
the  surgeon  has  four  methods  at  his  disposal.  These  are  (c)  the  cystoscopic, 
wherein  the  tumors  are  attacked  by  means  of  the  high-frequency  current,  snare, 
or  cautery  manipulated  through  a  cystoscope;  (b)  cystotomy,  with  excision  of 
the  tumors;   (c)  resection  of  the  bladder;   (d)  extirpation  of  the  bladder. 

The  exact  method  to  be  followed  varies  with  the  character  of  the  tumor. 
Where  possible  cystoscopic  methods  should  be  used,  as  they  are  the  simplest, 
incapacitate  the  patient  least,  are  least  dangerous,  and,  for  the  destruction  of 
tumors  to  which  they  are  applicable,  are  most  efficient.  Of  the  cystoscopic 
methods,  that  employing  the  Oudin  monopolar  high-frequency  current  is  the 


Fig.   282. — Cautery  resection  of  papilloma  of  the  bladder.     (Mayo's  Clinics, 
W.  B.  Saunders  Co.) 

most  used  and  gives  the  best  results.  Papillomata  yield  readily  to  it;  myxomata 
with  greater  Oimcuity.  Ihe  denser  benign  tumors  are  not  suitaoie  lor  this 
method  of  attack,  nor  are  the  malignant  neoplasms.  The  details  of  the  method 
of  application  will  be  found  on  page  56. 

Geraghty  has  found  the  use  of  radium,  applied  by  means  of  a  special  cysto- 
scope directly  to  the  tumor,  in  doses  of  500  or  600  milligramme-hours,  some- 
times alone  and  sometimes  in  combination  with  the  high-frequency  current,  to 
be  of  value  in  the  treatment  of  malignant  papillomata,  which  yielded  but  slowly 
or  not  at  all  to  the  electric  treatment  alone. 

The  immediate  results  of  the  treatment  of  papillomata  by  high-frequency 
desiccation  have  been  uniformly  good,  the  growths  disappearing  after  a  varying 
number  of  treatments.  In  some  of  the  cases  there  have  been  recurrences,  but 
not  in  as  many  as  when  other  methods  have  been  used,  and  in  the  event  of  such 


554 


GENITO-URINARY  SURGERY 


recurrences  it  has  not  been  difficult  to  obtain  the  patients'  consent  to  a  repetition 
of  the  treatment. 

The  use  of  the  snare  and  cautery  presents  considerable  difficulty,  and  re- 
quires apparatus  of  special  design,  so  that  they  are  now  but  little  used. 

Cystotomy  and   Cystectomy 
The  bladder  may  be  approached  above  the  pubis  either  extra-  or  trans-peri- 
toneally.    The  former  is  the  older  method,  is  the  safer  as  regards  infection,  but 
has  been  discarded  by  some  surgeons  on  account  of  the. excellent  exposure  they 


Fig.  283. — Removal  of  large  amount  of  bladder  with  transplantation  of  ureter. 
(Mayo's  Clinics,  W.  B.  fciaunders  Co.) 

were  able  to  obtain  by  the  transperitoneal  method,  which  also  permits  explora- 
tion of  the  liver  and  lymphatics  for  metastases.  Yet  by  the  procedure  advo- 
cated by  Squier  abundant  room  is  provided  by  the  extraperitoneal  route,  and 
the  exposure  is  as  good  as  in  the  transperitoneal  operation. 

According  to  the  character  and  location  of  the  tumor,  the  choice  of  the 
operative  procedure  should  be  as  follows: 

WTien  the  tumor  is  apparently  benign,  but  for  any  reason  excision  is  chosen 
instead  of  the  high-frequency  destruction  through  a  cystoscope,  cystotomy 
may  be  performed  as  described  for  the  removal  of  stone,  the  bladder  incision 


SURGERY  OF  THE  BLADDER 


555 


being  made  of  sufficient  size  to  provide  a  good  exposure  when  the  patient  is 
placed  in  the  Trendelenburg  position  and  retractors  are  inserted.  The  tumor  or 
tumors  are  removed  by  grasping  close  to  the  bladder-wall  with  a  clamp  and 
dividing  the  base  with  the  cautery.  The  operation  is  concluded  by  thoroughly 
flushing  the  bladder  with  1  to  4000  protargol  and  closing  the  incision  about  a 
drainage-tube,  or  completely  suturing  the  vesical  wound.  The  prevesical  space 
must  always  be  drained.    To  avoid  transplantation  of  the  tumor  to  other  parts 


Fig.  284.- 


-Showing  method  of  closure  of  bladder  incisiun. 
W.  B.  Saunders  Co.) 


(Mayo's   Clinics, 


of  the  bladder,  preliminary  cauterization  of  the  neoplasm  and  the  use  of  alcohol- 
wet  sponges  are  suggested  by  Geraghty. 

The  transperitoneal  route  should  be  chosen  for  the  removal  of  tumors  of 
a  probably  malignant  nature  situated  on  those  parts  of  the  bladder-wall  which 
have  a  peritoneal  investment,  as  it  is  then  easier  to  remove  the  whole  thickness 
of  the  walls,  including  the  peritoneal  coat. 

The  bladder  is  irrigated  and  emptied,  and  the  patient  placed  in  the  Tren- 
delenburg position.  An  incision  is  then  made  from  the  umbilicus  to  the 
symphysis,  the  liver  and  lymphatics  searched  for  metastases,  and  the  intestines 
gauze-packed  into  the  upper  portion  of  the  abdomen.     The  bladder  is  then 


556 


GENITO-URINARY  SURGERY 


drawn  up  into  the  wound  by  means  of  forceps  and  an  incision  made  about  the 
tumor.  When  this  approach  is  used  for  tumors  situated  near  the  base  of  the 
bladder  an  incision  for  inspection  is  made  in  the  posterior  wall;  in  the  case  of 
apparently  benign  tumors  removal  is  then  effected  by  means  of  the  cautery,  as 
through  the  suprapubic  opening  (Fig.  282);  if  malignancy  is  probable,  an 
incision  is  carried  down  and  around  the  tumor.  Should  it  be  necessary  to  divide 
a  ureter,  the  proximal  portion  is  brought  out  through  an  incision  in  the  peri- 


FiG.  285. — Gushing  peritoneal  suture  closing  bladder  wound,     (Mayo's  Clinics, 
W.  B.  Saunders  Co.) 

toneum  and  inserted  into  the  bladder  at  the  most  convenient  point  (Fig.  283). 
The  ureter  should  be  covered  over  with  a  fold  of  peritoneum  before  completing 
the  operation.  The  wound  in  the  bladder  is  closed,  as  recommended  by  Judd, 
by  means  of  a  continuous  Connell  stitch  of  catgut  (Fig.  284),  passing  through 
all  the  coats  of  the  viscus,  the  knots  and  loops  being  placed  on  the  mucous 
surface,  as  in  suturing  the  intestine.  Should  a  portion  of  the  bladder  incision 
be  through  an  extraperitoneal  portion,  Judd  recommends  that  when  possible 
the  peritoneum  be  drawn  down  so  as  to  be  included  in  the  suture.    A  second 


SURGERY  OF  THE  BLADDER  557 

suture  line  should  be  placed  over  the  first,  the  peritoneum  alone  being  in- 
cluded (Fig.  285);  the  stitches  are  placed  parallel  to  the  Hne  of  incision,  after 
the  method  of  Gushing.  Drainage  of  the  bladder  and  of  the  peritoneal  cavity- 
is  necessary  when  there  has  been  transplantation  of  a  ureter  and  when  soiling 
of  the  wound  has  occurred. 

The  extraperitoneal  operation  is  performed  by  Squier  in  the  following  man- 
ner: The  abdominal  parietes  are  incised  down  to  the  peritoneum  from  one 
inch  above  the  umbilicus  on  the  left  side  to  the  symphysis,  the  sheath  of  the 
rectus  being  opened,  and  that  muscle  displaced  outward.  By  sponging  the  fat 
upward  the  urachus  and  obliterated  hypogastric  arteries  are  exposed.  In  some 
cases  Squier  opens  the  peritoneum  at  this  point,  in  others  proceeds  extraperi- 
toneally  as  here  described. 

By  making  traction  on  the  urachus  the  hypogastrics  are  made  prominent, 
the  left  one  being  grasped  with  forceps  and  drawn  to  the  right.  Then  by  blunt 
dissection  between  this  structure  and  the  wall  of  the  pelvis  the  vas  is  brought 
into  view,  and  is  followed  downward  till  the  ureter  is  exposed,  it  being  crossed 
by  the  vas  just  before  entering  the  bladder.  After  exposing  the  right  ureter  in 
a  similar  manner,  the  urachus  is  divided  close  to  the  bladder,  and  the  peritoneum 
is  stripped  from  the  posterior  surface,  the  bladder  thus  being  freed  except  in 
front,  where  the  attachments  to  the  pubis  are  left  intact. 

From  this  point  the  operation  is  similar  to  the  transperitoneal  operation 
described.  Squier  advocates  bladder  drainage  with  a  26  F.  catheter  through  a 
stab  wound  in  the  anterior  wall. 

Whatever  method  is  followed,  it  is  essential  to  have  some  source  of  artificial 
illumination.  This  may  conveniently  be  worn  on  the  forehead,  a  small  battery 
being  hung  at  the  hip,  or  a  small  lamp  may  be  placed  on  the  retractor,  or  the 
lamp  of  a  cystoscope  inserted  through  the  urethra  may  be  used. 

Extirpation   of  the    Bladder 

Hartley  collected  twenty-three  cases  of  complete  removal  of  this  organ  for 
malignant  disease.  The  total  recoveries  ^ere  twelve,  giving  a  mortality  of 
forty-seven  and  eighty-three  one-hundredths  per  cent.  Five  patients  died  during 
operation,  three  of  collapse  afterward,  and  four  a  few  days  later. 

The  ureters  were  implanted  into  the  bowel  in  eleven  cases  with  six  deaths, 
and  into  the  vagina  in  seven  cases  with  one  death  from  shock.  In  this  operation, 
formidable  as  it  seems  to  be,  the  chief  difficulty  is  not  the  removal  of  the 
bladder,  but  the  disposition  of  the  ureters.    Four  procedures  are  practised: 

1.  Ligature  of  the  ureter,  followed  by  double  nephrostomy. 

2.  Implantation  into  the  colon. 

3.  Implanation  into  the  vagina. 

4.  Ureterostomy  in  the  skin  wound.  Of  these,  double  nephrostomy  gives 
the  most  encouraging  results. 

The  operation  is  indicated  only  in  cases  in  which  complete  removal  of  the 
malignant  disease  is  impossible  by  partial  resection  (i.e.,  where  there  is  ex- 
tensive involvement  of  the  bladder  base,  or  where  the  urethral  orifice  is  in- 
cluded), and  in  which  it  is  possible  to  remove  all  the  disease  by  cystectomy. 
It  is  contra-indicated  when  the  malignant  disease  has  extended  beyond  the 
bladder,  at  least  when  more  than  the  prostate  and  seminal  vesicles  are  involved. 


558  GENITO-URINARY  SURGERY 

I"he  patient  is  placed  in  the  Trendelenburg  posture,  the  bladder  is  distended, 
and  a  vertical  incision  four  or  five  inches  long  is  made  in  the  median  line  as 
in  suprapubic  cystotomy,  but  extending  higher.  This  exposes  the  bladder  and 
the  reflection  of  peritoneum,  the  latter  being  pushed  well  upward.  A  trans- 
verse incision  is  made  from  the  lower  end  of  the  wound,  dividing  all  the  parietal 
structures  to  each  external  inguinal  ring  just  above  the  pubic  bone  and  Pou- 
part's  ligament.  The  rectangular  flaps  thus  outlined  are  dissected  and  retracted 
upward  and  outward  to  allow  free  access  to  the  bladder.  While  moderate  trac- 
tion is  made  upward  on  the  lateral  aspects  of  the  bladder,  the  anterior  wall 
is  separated  by  blunt  dissection  from  the  pubis  down  to  the  vesical  neck,  which 
is  exposed,  isolated,  and  clamped  tightly  with  two  pairs  of  Spencer  Wells  forceps. 
The  neck  of  the  bladder  is  divided  between  the  forceps  and  each  stump  cau- 
terized. The  peritoneum  is  carefully  peeled  and  removed  from  the  superior, 
posterior,  and  lateral  aspects  of  the  bladder  by  blunt  dissection,  preferably  with 
the  finger,  avoiding  opening  the  peritoneal  cavity.  The  inferior  vesical  arteries 
and  ureters  are  secured  close  to  the  bladder  with  large  curved  haemostats  and 
divided  between  the  forceps  en  masse.  The  ureteral  openings  are  cauterized 
at  each  end  and  the  vesical  arteries  ligated,  after  which  the  base  of  the  bladder 
may  be  carefully  separated  from  its  attachments  and  the  viscus  removed.  The 
stump  of  the  urethra  is  ligated,  all  bleeding  stopped,  and  the  deep  wound 
packed  with  gauze,  the  drainage  being  brought  out  just  over  the  symphysis. 
Both  transverse  cuts  and  most  of  the  median  incision  are  sutured,  and  the 
external  wound  dressed. 

Harris  advises,  especially  if  the  prostate  is  involved,  division  of  the  urethra 
at  the  triangular  ligament  while  traction  is  made  on  the  bladder  anteriorly, 
and  removing  the  bladder  and  prostate  together,  these  being  separated  from 
the  rectum  while  an  assistant's  finger  is  inserted  in  the  latter. 

Complications    and   Sequelae 

These  are  similar  to  those  described  under  suprapubic  cystotomy  for  the 
removal  of  stone.  Since  an  operation  for  the  removal  of  tumor  is  prolonged 
and  is  often  attended  by  profuse  hemorrhage,  shock  and  collapse  are  particularly 
to  be  guarded  against.  Should  the  patient  escape  these  dangers,  suppression 
of  urine,  urinary  fever,  or  infection  of  the  kidneys  may  develop.  The  most 
frequent  complication  is,  however,  urinary  infiltration  with  cellulitis.  Should 
symptoms  point  to  these  conditions,  the  hypogastric  wound  should  be  opened 
and  the  space  of  Retzius  thoroughly  drained. 

Postoperative  Treatment. — After  a  tumor  has  been  treated  by  means  of 
the  high-frequency  current  no  special  care  is  required  in  the  great  majority  of 
cases;  in  occasional  instances  there  is  an  increment  of  bleeding,  making  it  ad- 
visable for  the  patient  to  stay  in  bed  for  twenty-four  hours. 

After  removal  of  tumors  by  any  of  the  various  cutting  operations  it  is  well 
to  irrigate  the  bladder  daily,  or  twice  daily,  with  a  mild  antiseptic  solution 
{e.g.,  1  to  4000  protargol),  either  through  the  bladder  drain,  or  by  means  of  a 
short  metal  nozzle  or  a  catheter,  the  method  giving  the  least  distress  and 
spasm  being  used. 


SURGERY  OF  THE  BLADDER  559 

After  the  removal  of  a  vesical  tumor  the  patient  should  be  examined  cys- 
toscopically  every  three  to  six  months  for  at  least  three  years,  that  should  there 
be  recurrences  these  may  be  detected  soon  after  their  appearance. 

PARAVESICAL  TUMORS 

These  may  be  solid  or  cystic. 

Myoma  is  the  only  solid  tumor.  Belfield  has  observed  one  case,  the  growth 
springing  from  the  muscular  tunic  and  projecting  as  a  nodule.  Verhoogen 
found  a  myoma  the  size  of  a  child's  head  attached  to  the  posterior  surface  of 
the  bladder  by  a  pedicle  about  as  thick  as  three  fingers. 

Residual  cysts  are  due  to  proliferation  of  the  remains  of  foetal  structures. 
Englisch  has  described  cysts  of  the  Wolffian  and  Miiller's  bodies,  of  the  prostatic 
utricle,  and  of  the  seminal  vesicles,  also  of  the  urachus. 

Inclusion  cysts — i.e.^  dermoids — have  been  already  described. 

There  is  but  one  example  of  simple  cyst,  contributed  by  Segond.  The 
tumor  was  found  in  the  muscular  wall  of  the  bladder.  It  was  tightly  adherent. 
Clado  suggests  that  it  may  have  originated  from  an  intravesical  glandular  cyst. 

Cysts  developing  in  the  prostatic  utricle  and  seminal  vesicles  are  compara- 
tively rare.  Utricular  cysts  are  median,  provided  with  a  pedicle  attached  to 
the  base  of  the  prostate,  and  develop  behind  the  bladder.  Those  which  arise 
from  dilatation  of  diverticula  of  the  seminal  vesicle  are  always  lateral.  The 
median  cysts  are  due  to  persistence  of  debris  in  the  duct  of  Miiller. 

Urachus  Cyst. — Very  exceptionally  the  urachus  may  remain  patent 
throughout  its  course  or  at  one  end,  giving  rise  to  a  cyst  or  fistula.  The  cyst 
will  form  an  irregular  fluctuating  hypogastric  tumor  simulating  sacculated 
bladder. 

Hydatid  cysts  develop  in  the  pericystic  tissue.  If  the  cyst  develops  in 
either  the  anterior  or  the  posterior  wall  of  the  space  of  Retzius,  its  direction 
of  growth  will  be  limited  by  the  fascia  surrounding  this  space.  It  will  then  grow 
upward  towards  the  umbilicus,  but  will  not  reach  higher  than  this  point.  It 
may  develop  in  the  cellular  tissue  separating  the  bladder  from  the  rectum,  or  it 
may  occupy  the  true  pelvis,  in, this  case  growing  upward  towards  the  umbilicus. 

These  cysts  may  be  single  or  multiple,  and  are  prone  to  contract  adhesions 
to  the  bladder  and  pelvic  fascia.  The  primitive  development  of  the  tumors  is 
in  the  subperitoneal  cellular  tissue:  hence  the  treatment  of  these  cysts  does 
not  necessitate  cystotomy. 

A  fluctuating  tumor  projecting  into  the  hypogastrium  should  be  extirpated 
if  possible;  if  this  is  impracticable,  the  lining  membrane  should  be  removed 
and  the  cavity  drained.  A  cyst  filling  the  vesicorectal  cul-de-sac  should  be 
reached  by  the  crescentic  perineal  incision  described  as  appropriate  for  the  rC' 
moval  of  seminal  vesicles.    It  can  be  enucleated,  extirpated,  or  drained. 

Intravesical  ureteral  cyst  has  been  occasionally  seen  as  a  result  of  con- 
striction at  the  entrance  of  this  canal  into  the  bladder,  where  the  stricture 
occurs  at  the  termination  of  the  ureter  on  the  vesical  mucous  membrane.  In 
cases  of  such  exceedingly  rare  conditions  there  are  generally  hydronephrosis 
and  congenital  abnormal  location  of  the  ureteral  termination.  The  condition 
is  really  hydro-ureter,  with  vesical  invagination. 


CHAPTER  XXV 

SURGERY  OF  THE  URETERS 

ANATOMY 

The  ureters  are  slightly  flattened,  tough,  white,  fibro-muscular  canals,  which 
conduct  the  urine  from  the  kidneys  to  the  bladder,  with  the  investments  of 
which  their  three  coats  are  continuous.  On  an  average  they  are  from  twenty- 
seven  to  thirty-five  centimetres  in  length.  Exceptionally  they  may  be  longer, 
though  a  greater  length  than  forty  centimetres  has  not  been  recorded.  They 
are  about  three  to  four  millimetres  in  diameter,  but  are  not  of  uniform  calibre 
throughout,  being  slightly  narrowed — (1)  at  the  point  of  juncture  of  the  pelvis 
and  ureter;  (2)  at  the  point  of  crossing  the  bifurcation  of  the  ihac  artery; 
(3)  at  the  point  of  entrance  into  the  bladder.  When  strictured,  or  as  the  result 
-of  urethral  obstruction,  the  ureters  may  become  enormously  dilated,  reaching  the 
size  of  the  small  intestine. 

The  course  of  the  ureters  is  in  general  downward  and  inward.  They  are 
separated  by  an  interval  of  about  three  inches  at  their  upper  portion  and  less 
than  two  inches  where  they  enter  the  bladder.  Their  course  in  their  abdominal 
portion  is  indicated  on  the  surface  by  a  vertical  line  passing  upward  from  the 
junction  of  the  inner  and  middle  thirds  of  Poupart's  ligament.  The  upper  ex- 
tremity of  the  ureter  corresponds  to  a  point  where  this  line  crosses  the  twelfth 
rib.  The  lower  extremity  of  the  abdominal  portion  of  the  ureter,  corresponding 
to  the  crossing  of  the  bifurcation  of  the  common  iliac  artery,  is  placed  slightly 
below  the  point  where  this  vertical  line  intersects  a  line  joining  the  two  anterior 
superior  iliac  spines.     (Tourneur.) 

At  its  point  of  origin  from  the  kidney  pelvis  the  ureter  lies  on  a  plane  behind 
that  of  the  renal  artery.  It  passes  downward  and  inward,  crossing  the  psoas 
muscle  obliquely  to  the  bifurcation  of  the  common  iliac  artery.  In  its  course 
it  is  slightly  convex  forward  and  inward.  About  the  middle  of  its  course,  or 
a  little  below  this  point,  the  abdominal  portion  of  the  ureter  is  crossed  by  the 
spermatic  artery  in  the  male  and  by  the  ovarian  vessels  in  the  female.  In  front 
lie  the  caecum  and  the  ascending  colon  on  the  right  side,  the  sigmoid  flexure 
on  the  left  side. 

The  pelvic  portion  of  the  ureter  describes  a  curve  with  its  concavity  forward, 
inward,  and  upward.  It  passes  beneath  the  peritoneum,  along  the  walls  of  the 
pelvis,  and,  entering  the  posterior  false  ligament  of  the  bladder,  crossed  by  the 
vas  deferens  in  the  male,  obliquely  pierces  the  vesical  coats  just  below  and  to 
the  outer  side  of  the  upper  extremity  of  the  seminal  vesicle. 

In  the  female  the  pelvic  portions  of  the  ureters  pass  first  downward,  then 
forward  and  inward,  in  the  loose  cellular  tissue  of  the  pelvis.  In  the  vase  of 
the  broad  ligament  they  lie  beneath  the  uterine  arteries,  which  are  in  close 
relation  to  them  for  a  short  distance  as  they  pass  upward  to  the  uterus:  the 
ureters  are  continued  forward  over  the  anterior  vaginal  vault  into  the  bladder. 
560 


SURGERY  OF  THE  URETERS  561 

The  vesical  portion  of  the  ureter,  about  three-quarters  of  an  inch  in  length, 
runs  obliquely  inward  and  forward  through  the  muscular  layer  of  the  bladder- 
wall,  opening  into  the  cavity  of  this  viscus  by  a  slit-like  orifice  about  three 
centimetres  from  its  fellow  of  the  opposite  side,  and  an  equal  distance  from 
the  urethral  orifice,  the  three  openings  marking  the  angles  of  the  vesical 
trigonum. 

The  muscles  of  the  ureter  are  continuous  with  those  of  the  bladder.  Testut 
describes  a  valve-like  arrangement  due  to  absence  of  muscular  tissue  in  the 
upper  wall  of  the  terminal  extremity  of  the  ureter.  This  portion  of  the  wall 
is  made  up  entirely  of  a  fold  of  mucous  membrane;  intravesical  tension  at  once 
presses  this  valve-like  fold  against  the  low  ureteral  wall,  and  thus  effectually 
blocks  the  tube.  Either  because  of  this  arrangement  or  on  account  of  the 
objique  manner  in  which  the  ureter  passes  through  the  bladder-wall,  the  normal 
orifice  does  not  permit  regurgitation  of  urine. 

The  relation  of  the  ureter  to  the  peritoneum  is  important  from  a  surgical 
standpoint.  Cabot  has  shown  that  if  the  surgeon  in  stripping  up  the  peri- 
toneum has  reached  the  place  where  it  refuses  to  separate  readily  from  the 
parietes,  he  will  find  the  ureter  upon  the  stripped-up  peritoneum;  on  the  left 
side  from  half  an  inch  to  an  inch  outside  this  point;  on  the  right  side  at  a 
somewhat  greater  distance,  owing  to  the  ureter  being  displaced  laterally  by 
the  interposition  of  the  vena  cava  between  it  and  the  spine. 

The  pelvic  ureter  of  the  left  side  lies  anterior  to  and  to  the. outer  side  of  the 
internal  iliac  artery  close  to  the  rectum;  that  of  the  right  side  passes  down- 
ward parallel  to  the  internal  iliac  artery  and  directly  in  front.  As  these  canals 
descend  they  are  covered  by  peritoneum  to  the  point  where  this  membrane  is 
reflected  upward  over  the  posterior  wall  of  the  bladder,  leaving  nearly  an  inch, 
which  may  be  incised  through  the  vesical  walls  without  opening  the  peritoneal 
cavity. 

The  mucous  membrane  of  the  ureter  is  continuous  with  that  of  the  kidney 
pelvis  and  of  the  bladder.  Glands  are  either  rudimental  or  absent.  The 
mucous  surface  is  made  up  of  layers  of  stratified  squamous  or  transitional 
epithelium. 

The  blood-supply  is  derived  from  branches  of  the  renal,  spermatic  or 
ovarian,  and  from  the  ureteric  artery  springing  from  the  aorta  or  internal  or 
common  iliac  (Krause),  and  in  the  pelvic  portion  from  branches  of  the  inferior 
vesical  and  middle  hemorrhoidal  arteries.  These  vessels  supply  a  plexus  which 
abundantly  provides  for  repair  in  case  of  injury. 

The  nerves  are  derived  from  the  renal,  spermatic,  and  hypogastric  plexuses. 
Pain  originating  in  the  upper  extremity  of  the  ureter  is  referred  to  the  kidney; 
that  in  the  middle  portion  to  the  abdomen,  and  on  the  right  side  may  be 
indistinguishable  from  the  pain  of  appendicitis;  while  that  in  the  lower  ex- 
tremity is  referred  to  the  bladder  and  ureter.  Although,  as  a  rule,  the  above 
is  true  of  ureteral  referred  pain,  at  times  vesical  pain  is  the  sole  symptom  of 
a  lesion  of  the  renal  pelvis. 

The  lymphatics  are  not  distinguishable  as  networks  in  the  mucosa  or  sub- 
mucosa,  but  are  visible  as  such  in  the  muscular  coat  and  on  the  exterior.  The 
lymphatic  trunks  of  the  lower  segment  are  continuous  with  those  of  the  bladder, 
36 


562  GENITO-URINARY  SURGERY 

or  are  tributary  to  the  internal  iliac  nodes;  those  of  the  middle  segment  empty 
into  the  lumbar  nodes;  those  of  the  upper  segment  are  either  continuous  with 
the  renal  lymphatics  or  are  tributary  to  the  aortic  nodes.    Lymph  vessels  are 


Fig.   286. — Colloidal  silver  radiogram,  showinR   double  ureter   and   double  pelvis  on  left 
side.     (Selby.)     (Mayo's  Climes,  W.  B.  Saunders  Co.) 

also  run  from  the  lower  ureter  to  the  lymphatics  of  the  kidney  and  of  the  peri- 
renal fibrofatty  investment,  thus  providing  a  means  of  direct  transference  of 
infection  to  these  structures. 


SURGERY  OF  THE  URETERS 


563 


From  its  strong  muscular  coat,  it  is  evident  that  the  ureter  is  not  merely 
a  channel,  but  takes  an  active  part  in  conveying  the  excretion  of  the  kidney 
into  the  bladder.  It  is  well  established  that  the  unstriped  muscular  fibres  of 
the  ureter  are  in  a  state  of  intermittent  peristalsis.  This  action  goes  on  inde- 
pendently in  the  ureters.  The  contractions,  are  repeated  at  irregular 
intervals,  and  the  quantity  of  urine  discharged  at  each  contraction  varies  greatly, 
probably  averaging  from  three  to  ten  drops. 


Anomalies 

The  ureter  may  be  absent;  in  this  case  the  kidney  also  will  be  absent. 
Bruner  has  collected  forty-eight  cases  of  this  anomaly.  It  may  be  obliterated 
through  a  part  or  the  whole  of  its  course.  In  this  event  the  kidney  is  atrophic 
or  degenerated.    It  may  be  bifurcated  at  either  extremity  (Fig.  287,  C  and  D). 


Fig.  287. — Anomalous  ureters.    A  and  B,  double  ureters;  C  and  D,  bifurcated 
ureters. 


564 


GENITO-URINARY  SURGERY 


The  ureter  may  be  multiple.  Double  ureter  is  usually  associated  with  a  kidney 
which  has  two  pelves  (Figs.  286  and  Fig.  287,  A  and  B).  Nine  cases  of  bilateral 
duplication  are  reported  (Levison). 

A  fused  kidney  usually  possesses  two  distinct  pelves  and  ureters.  Each 
pelvis,  in  kidneys  with  more  than  two  pelves,  has  its  own  ureter.  In  the  event 
of  double  ureters,  the  one  arising  from  the  inferior  pole  of  the  kidney  enters 
the  bladder  normally  at  the  trigonal  angle;  the  one  springing  from  the  upper 
part  of  the  kidney  passes  posterior  to  the  other  ureter  and  empties  into  the 
bladder,  abnormally;  that  is,  below  the  orifice  of  its  fellow. 

The  ureter  may  pursue  an  aberrant  course.  This  anomaly  appears  to  be 
chiefly  in  females.     Cases  are  recorded  in  which  ureters  opened  into  the  ex- 


'4 


Aj\om.e4oi/s  BTood-vesseJS 
Fig.  288. — Ureter  obstructed  at  its  emergence 
from     pelvis     by     anomalous    vessels.   (Mayo's 
Clinics,  W.  B.Saunders  Co.). 


Foslty  fa.  seta.! 


Fig.  289. — Vessel  divided,  fascia  stripped  away, 
and  ureteropelvic  -  juncture  incised.  (Mayo's 
Clinics,  W.  B.  Saunders  Co.) 


ternal  urinary  meatus,  the  vagina,  a  pouch  near  the  bladder,  the  rectum,  the 
seminal  passages,  and  on  the  surface  of  the  labium  minus. 

Valve-formation  is  an  anomaly  of  serious  import,  and  may  be  either 
congenital  or  acquired;  hydronephrosis  is  frequently  the  resultant  condition. 
In  the  congenital  form,  in  place  of  leaving  the  renal  pelvis  by  a  funnel-shaped 
orifice  at  its  lowest  portion,  the  ureter  may  emerge  from  the  side  of  this  sac, 
often  at  an  acute  angle;  or  it  may  run  for  some  distance  in  the  wall  of  the 
kidney  pelvis. 

The  acquired  valve  is  generally  caused  by  the  distorting  effect  of  hydro- 
nephrosis upon  the  renal  pelvis,  the  least  supported  posterio-inferior  portion  of 
which  bags  downward. 


SURGERY  OF  THE  URETERS 


565 


The  diagnosis  may  be  established  by  ureteral  catheterization,  and  ureter- 
ography with  colloidal  silver,  in  conjunction  with  the  clinical  symptomatology. 

For  the  relief  of  valvular  obstruction  the  kidney  pelvis  and  the  upper  portion 
of  the  abdominal  ureter  are  thoroughly  exposed  by  the  lumbar  extraperitoneal 
incision.  The  ureter  is  incised  below  the  sac,  and  a  probe  passed  into  the 
pelvis  of  the  kidney.  The  valve,  or  the  inner  ureteral  wall,  should  the  obstruc- 
tion be  caused  by  the  ureter  running  upward  in  the  pelvic  wall,  is  divided  from 
above  downward  to  the  most  dependent  part  of  the  sac.  The  resulting  longi- 
tudinal wound  may  be  closed  by  drawing  its  corners  together,  thus  converting 
it  into  a  transverse  wound   (Fenger),  or  by  applying  numerous  fine  catgut 


0—-^  . 


Fig.    290. —  Wound   sutured   transversely. 
(Mayo's  Clinics,  W.  B.  Saunders  Co.) 


Fig.    291. — Fascial    flap    sutured    over    ureteral 
wound.      (Mayo's  Clinics,   W.  B.  Saunders  Co.) 


sutures  along  the  whole  course  of  the  incision  (Mynter)  (Figs.  288,  289,  290, 
and  291).  PHcation  of  the  redundant  pelvis  has  been  curative,  and  in  at  least 
one  case  an  anastomosis  has  been  made  between  the  pelvis  and  the  bladder. 
Uretero-ureterostomy  may  be  indicated  for  the  relief  of  obstructions  along  the 
course  of  the  ureter.  When  the  underlying  cause  of  the  hydronephrosis  and 
valvular  obstruction  has  been  a  movable  kidney,  the  organ  should  be  sutured 
in  place. 

Kinks  of  the  ureter  are  usually  acquired,  but  may  be  congenital.  They 
are  commonly  the  result  of  movable  kidney  and  cause  either  intermittent  or 
permanent  hydronephrosis.  Occasionally  they  may  be  caused  by  ureteral 
adhesions. 


556.  GENITO-URINARY  SURGERY 

The  diagnosis  depends  upon  X-ray  ureterography  in  conjunction  with  metal- 
ized  catheters  or  the  injection  of  colloidal  silver. 
The  treatment  lies  in  removing  the  cause. 

WOUNDS  AND  RUPTURE  OF  THE  URETERS 

Wounds  of  these  canals,  except  those  inflicted  during  the  course  of  surgical 
operations,  are  usually  attended  by  injuries  of  other  organs  immediately  threat- 
ening to  life.  The  ureter  may  be  wounded  by  direct  violence,  as  by  a  stab  or 
a  bullet,  or  may  be  ruptured  by  indirect  violence,  as  by  a  crush  or  a  blow. 
In  the  course  of  hysterectomy  division  of  the  ureter  is  comparatively  common. 
As  a  result  of  rupture  of  the  ureter  there  is  extravasation  of  urine.  If  this 
be  sterile  it  does  not  necessarily  excite  cellulitis,  and  in  case  the  ureter  is  not 
completely  torn  across  the  opening  may  cicatrize  and  the  extravasated  urine 
may  be  absorbed  or  become  encapsulated,  in  the  latter  case  producing  the 
condition  known  as  pseudo-hydronephrosis.  If  there  is  concomitant  infection 
cellulitis  will  result,  which,  unless  promptly  recognized  and  treated  surgically, 
spreads  rapidly  and  may  terminate  fatally.  Following  cicatrization  of  wounds 
strictures  may  be  formed  causing  hydronephrosis,  and,  finally,  total  destruction 
of  the  kidney. 

When  after  a  blow  in  the  lumbar  region  there  is  passage  of  bloody  urine 
with  the  formation  of  a  post-peritoneal  tumor  which  fluctuates  and  rapidly  and 
progressively  increases,  rupture  of  the  ureter  or  kidney  may  be  suspected.  A 
positive  diagnosis  is  usually  possible  by  the  X-ray  after  the  injection  of  col- 
loidal silver  through  a  ureteral  catheter,  but  the  method  is  not  without  danger. 
When,  some  weeks  or  months  after  injury  to  the  ureteral  region,  symptoms 
of  hydronephrosis  develop,  these  symptoms  suggest  partial  laceration  of  the 
ureter  followed  by  cicatricial  contraction. 

Wounds  of  the  ureter  inflicted  during  the  course  of  intra-abdominal  oper- 
ations are  usually  recognized,  because  the  white,  fibrous,  thick-walled  canal 
is  easily  identified,  and  because  there  will  probably  be  escape  of  urine  into 
the  wound. 

Accidental  ligation  of  a  single  ureter  causes  typical  renal  colic,  or  no 
symptoms  at  all,  followed,  if  the  condition  be  unrelieved,  by  atrophy  of  the 
corresponding  kidney,  provided  it  be  normal;  by  acute  pyelonephritis  if  the 
kidney  be  infected. 

Treatment. — When  symptoms  point  to  rupture  of  the  ureter  without  ex- 
ternal wound,  there  should  be  no  hesitation  in  making  an  extraperitoneal 
approach  to  the  seat  of  the  rupture,  draining  the  tissues  of  the  extravasated 
urine,  and  restoring  the  continuity  of  the  canal.  When  there  is  an  external 
wound  through  which  the  urine  escapes,  this  wound  should  be  followed  down 
to  the  ureter. 

If  the  wound  communicates  with  the  peritoneal  cavity,  the  incision  of 
choice  is  an  abdominal  one;  after  closure  of  the  ureteral  opening  the  peri- 
toneum is  brought  together  over  the  line  of  suture.  Drainage  should  be  in- 
serted extraperitoneally  down  to  the  wound  in  the  ureter;  abdominal  drainage 
should  also  be  employed  for  a  few  days. 


SURGERY  OF  THE  URETERS 


567 


Extraperitoneal  wounds,  if  longitudinal,  do  not  require  suture,  since  they 
heal  without  subsequently  encroaching  upon  the  lumen  of  the  canal.  If 
transverse  and  involving  half  of  the  lumen  of  the  ureter,  even  though  they 


Fig.  292. — End-in-side  anasiomo^is. 
(Van  Hook.) 


Fig.   293. —End-in  side     anasto- 
mosis, with  reinforcing  sutures. 


Fig.  294. — End-in-side  anastomosis.     (Emmet). 

be  sutured  and  unite  by  first  intention,  there  is  likely  to  be  cicatricial  con- 
traction which  will  ultimately  cause  stricture. 

Transverse  wounds  may  be  treated  by  making  from   the  middle   of   the 
transverse  cut  incisions  upward  and  downward  through  the  ureteral  walls  for 


568 


GENITO-URINARY  SURGERY 


a  sufficient  distance;  the  four  corners  formed  by  these  cross-cuts  are  trimmed 
off,  and  the  resulting  wound  is  united  transversely  by  folding  the  ureter  on 
itself.     (Fenger.) 

Complete  division  of  the  ureter  may  be  treated  by  end-in-side,  end-to- 
end,  or  end-in-end  suture.  End-in-side  (Van  Hook's  method)  ureteral  implan- 
tation is  thus  performed:  The  lower  end  of  the  ureter  is  ligated  from  one- 
eighth  to  one-fourth  of  an  inch  from  its  free  end.  With  a  sharp-pointed 
scissors  a  longitudinal  cut  is  made  in  the  lower  end  of  the  ureter,  twice  as 
long  as  its  diameter,  one-fourth  of  an  inch  below  the  ligature.  The  upper 
end  of  the  ureter  is  split  by  passing  a  point  of  the  scissors  one-fourth  of  an 
inch  within  its  lumen  and  cutting  through  the  wall.  Two  very  small  needles, 
placed  on  each  end  of  a  catgut  suture,  are  then  passed  through  the  wall  of 


Fig.  295. — End-in-end  anastomosis. 

the  upper  ureteral  end  one-eighth  of  an  inch  from  its  extremity;  the  needle- 
punctures  are  made  from  one-sixteenth  to  one-eighth  of  an  inch  apart,  and 
are  equally  distant  from  the  end  of  the  ureter  (Fig.  292).  The  needles  are 
then  carried  through  the  slit  in  the  side  of  the  lower  end  of  the  ureter  and 
along  the  lumen  of  the  canal  for  half  an  inch;  at  this  point  they  are  pushed 
through  the  ureteral  wall  side  by  side.  Traction  upon  the  catgut  suture 
will  pull  the  upper  ureteral  extremity  into  the  slit  made  in  the  lower  ex- 
tremity. When  this  has  been  done  the  ends  of  the  loop  are  securely  tied 
(Fig.  292).  If  this  operation  has  been  done  through  the  peritoneal  cavity 
it  should  be  completed  by  covering  the  seat  of  suture  by  a  double  layer  of 
peritoneum.  The  implantation  may  be  strensrthened  by  one  or  two  sutures 
securing  the  wall  of  the  proximal  ureteral  end  to  the  margins  of  the  longi- 
tudinal incision  made  in  the  distal  end  (Fig.  293). 


SURGERY  OF  THE  URETERS 


569 


In  case  of  dilatation  of  the  upper  end  to  be  united,  Emmet  suggests  puck- 
ering this  end  by  three  sutures  to  draw  the  upper  end  in  place  (Fig.  294). 
When  there  is  insufficient  tissue  to  perform  an  end-in-side  anastomosis, 
an  end-in-end  or  end-to-end  anastomosis  should  be  effected.     The  methods 
of  performing  these  operations  are  indicated  in  Figs.   295   and   296. 

All  of  the  methods  described  have  given  good  results.  The  ureter,  on 
account  of  its  very  free  blood  supply,  is  well  adapted  to  the  performance  of 
plastic  operations.  All  sutures  which  enter  the  lumen  of  the  canal  should  be 
of  catgut  to  avoid  the  formation  of  fistulse  or  incrustations;  sutures  which 
are  placed  entirely  in  the  outer  coats  should  be  of  silk. 

When  the  ureter  is  torn  across,  and  so  much  of  it  is  destroyed  that 
ureteral  anastomosis  is  not  possible,  it  should  be  implanted  into  the  bladder, 
if  this  is  practicable,  by  either  the  extraperitoneal  or  the  intraperitoneal  route; 
the  latter  is  usually  the  only  feasible  method  of  performing  the  operation. 

Vesical  Implantation. — Payne's  successful  method  is 
performed  by  passing  a  sound  through  the  urethra,  and  by 
means  of  the  tip  causing  the  wall  of  the  emptied  bladder  to 
project  at  a  point  as  near  the  trigone  as  the  conditions  will 
allow.  A  short  antero-posterior  incision  is  made  on  the  point 
of  the  sound.  The  divided  end  of  the  ureter  is  then  split 
for  a  short  distance  on  each  side,  and  is  carried  into  the 
bladder  for  some  distance  by  means  of  mattress  sutures  passed 
through  the -flaps,  then  through  the  bladder  wound,  and  out 
through  the  bladder-wall,  to  be  tied  on  the  peritoneal  surface 
(see  Figs.  297  and  298).  Additional  sutures  are  inserted 
about  the  anastomosis  to  unite  the  serous  and  muscular  coats 
of  the  bladder  to  the  ureter.  Finally  a  loose  fold  of  peri- 
toneum or  omentum  is  fastened  around  the  utero-vesical 
anastomosis.  This  fold,  designed  to  prevent  leakage  and 
add  strength  to  the  junction,  must  not  be  drawn  tight 
enough  to  cause  constriction.  The  distal  portion  of  the 
divided  ureter  should  be  ligated,  the  cross-section  above 
the  ligature  being  cauterized  with  pure  carbolic  acid. 
Drainage  is  not  required. 

When  the  ureter  is  too  short  to  easily  reach  the  bladder  downward, 
dislocation  of  the  kidney  has  been  resorted  to,  to  make  an  anastomosis 
possible. 

If  the  ureteral  defect  is  so  far  removed  from  the  bladder  that  neither 
vesical  implantation  nor  ureteral  juncture  is  possible,  the  two  ends  may  be 
brought  to  the  surface,  as  proposed  by  Rydygier,  and  an  effort  made  to 
connect  them  by  forming  a  channel  of  skin.  Or  the  ureter  may  be  implanted 
upon  the  skin  surface.  Implantation  into  the  colon  is  difficult,  and  in  the 
light  of  present  evidence  may  be  expected  practically  always  to  be  followed 
by  kidney  infection.  Colonic  implantation  is  attended  by  a  hea\y  mortality 
(sixty-one  per  cent.,  Keyes),  ascending  infection  being  common  even  when 
the  ureters  are  made  to  traverse  the  walls  of  the  bowel  obliquely  and  their 
orifices  are  protected  by  tongue-shaped  flaps  of  mucous  membrane. 


Fig.  296. — Oblique  end 
to-end  anastomosis. 


570 


GENITO-URINARY  SURGERY 


Fig.  297. —  Method  of  drawing  ureter  through  bladder-wall.      (Payne.) 
(Journal  American  Medical  Association,  October  18,  1908.) 


-JlC.  ^8. — Cross-section  of  anastomosis  complete:    a,  traction  suture  tied 
c,  vesico-ureteral  sutures  tied.     (Payne). 


SURGERY  OF  THE  URETERS  571 

Implantation  into  the  skin  commonly  gives  unsatisfactory  drainage.  The 
operation  of  choice  when  the  opposite  kidney  is  known  to  be  functionally  suffi- 
cient is  nephrectomy;  when  the  renal  function  has  not  been  determined,  or  is 
known  to  be  deficient,  a  nephrostomy  should  be  performed. 

URETERITIS 

Infection  extends  from  the  bladder,  as  in  gonorrhoea,  from  the  kidney, 
as  in  pyonephrosis  of  haematogenous  origin  or  tuberculosis,  or  from  peri-ureteric 
tissues,  as  in  appendicitis  or  perinephric  abscess.  Congestion  strongly  pre- 
disposes to  infection,  and  is  caused  by  traumatism,  pressure  of  tumors,  dis- 
tention of  the  ureters,  lodgement  or  passage  of  calculus  or  clot,  or  the  passage 
of  irritating   urine. 

The  lesions  produced  by  ureteritis  are  similar  to  those  observed  in  cystitis. 
In  the  absence  of  distinct  glands  in  this  part  of  the  urinary  tract,  complica- 
tions akin  to  folliculitis  and  periurethral  abscess  observed  in  urethritis  are  not 
likely  to  occur. 

As  a  result  of  hyperaemia  and  inflammatory  swelling,  it  is  apparent  that 
the  lumen  of  the  ureters  may  be  seriously  encroached  upon.  If  the  inflam- 
mation extends  beyond  the  mucous  membrane,  involving  the  muscular  coat, 
there  may  be  resulting  atrophy,  with  loss  of  peristaltic  power.  From  long- 
standing inflammation  and  the  deposition  of  inflammatory  material  strictures 
may  form. 

Jaksch  reports  a  case  of  membranous  ureteritis  in  which  translucent  casts 
of  the  ureter  were  discharged  from  the  urine. 

Symptoms  of  ureteritis  are  not  definite.  It  is  nearly  always  associated 
with  cystitis  or  pyelitis,  the  symptoms  of  which  completely  mask  the  inflam- 
mation of  the  ureter.  Tenderness  on  palpation  is  perhaps  the  only  symptom 
which  would  even  suggest  inflami^iation.  In  the  urine  there  may  be  found 
masses  of  squamous  epithelium  without  pus.     (Garceau.) 

Kelly  states  that  a  normal  ureter  can  be  traced  and  immediately  exam- 
ined in  the  upper  part  of  the  pelvic  course  by  introducing  a  ureteral  catheter 
and  carrying  it  up  to  or  over  the  brim  of  the  pelvis.  When  an  inflexible 
catheter  is  thus  carried  over  the  brim  the  ureter  is  displaced  upward  and 
straightened  out,  and  can  be  palpated  through  the  rectum,  and  any  alterations 
in  its  calibre  noted  almost  as  minutely  as  when  laid  bare  by  dissection. 

The  palpation  of  the  ureter  through  the  abdominal  wall  for  the  purpose 
of  detecting  tenderness  is  sometimes  practicable,  pressure  being  made  at  the 
intersection  of  the  line  joining  the  anterior  superior  iliac  spines  with  one 
vertical  to  this  running  upward  from  the  junction  of  the  inner  and  middle 
thirds  of  Poupart's  ligament.  Clinical  experience  has  shown,  however,  that 
even  extreme  tenderness  elicited  by  deep  pressure  over  this  part  is  not  pathog- 
nomonic of  ureteritis. 

Treatment. — The  treatment  of  ureteritis  is  that  of  the  main  disease  which 
masks  it.  Instillations  and  irrigations  such  as  are  used  in  the  treatment  of 
cystitis  are  serviceable. 


572 


GENITO-URINARY  SURGERY 


STRICTURE  OF  THE  URETER 

This  may  be  congenital  or  acquired.  The  acquired  stricture  may  be  in- 
flammatory or  traumatic.  Congenital  stricture  has  been  regarded  as  the  com- 
monest form  of  narrowing.  Tuffier  reports  twenty-nine  cases.  In  fifteen  the 
narrowing  was  in  the  upper  part  of  the  ureter;  in  the  remainder  it  was  in 
the  lower  part. 

Inflammatory  stricture  is  apparently  more  common  than  pathological  rec- 
ords would  lead  us  to  believe,  and  is  usually  multiple.  Watson  has  reported 
two  cases. 

Traumatic  strictures  are  necessarily  rare,  since  there  are  comparatively 
few  cases  of  ureteral  wound. 

The  symptoms  of  ureteral  stricture  are  those  of  back  pressure.     Should 

the  stricture  produce  complete  oblitera- 
tion of  the  ureter,  the  kidney  will 
atrophy.  Partial  occlusion  causes  hy- 
dronephrosis and  great  dilatation  of  the 
ureter  above  the  seat  of  narrowing. 

The  diagnosis  of  ureteral  stricture 
is  founded  upon  the  development  of 
hydronephrosis,  and  direct  exploration 
of  the  ureter  by  means  of  catheters  or 
bougies,  and  by  radiography.  Cysto- 
scopic  examination  shows  an  abnormal 
condition  of  the  ureteral  orifice  and  the 
surrounding  mucous  membrane.  The 
ureteral  catheter  is  arrested  at  the  seat 
of  narrowing;  v/hen  after  persistent 
pressure  it  has  passed  through  there  is 
a  continuous  flow  of  urine.  Injection 
of  fluid,  since  it  results  in  sudden  in- 
crease of  renal  tension,  causes  pain,  the 
coarctation  preventing  the  fluid  from 
passing  into  the  bladder  between  the 
catheter  and  the  ureteral  walls.  As  the 
instrument  is  withdrawn,  its  tip  is  felt  to  slip  from  the  grasp  of  the  stricture. 

The  prognosis  of  ureteral  stricture  is  grave  because  of  the  usually  asso- 
ciated renal  involvement.  The  condition  is  rarely  suspected  till  pyelitis,  hydro- 
nephrosis, or  pyonephrosis  develops.  Strictures  of  the  lower  segment  are  more 
easily  cured  than  higher  ones;-  those  due  to  periureteral  contracture  recur 
even  when  fully  dilated. 

Treatment. — A  permeable  stricture  may  be  treated  by  (1)  intermittent 
dilatation,  beginning  with  a  bougie  or  catheter  one  millimetre  in  diameter 
and  increasing  to  four  millimetres;  the  treatments  being  practised  twice  a  week, 
and  being  preceded  by  vesical  irrigations  and  followed  by  ureteral  irrigations 
of  boric  acid  1  to  100  or  protargol  1  to  3000.  (2)  Continuous  dilatation, 
the  catheter  being  left  in  place  for  one  or  two  days  and  then  changed  to  a 
larger  instrument  until  full  dilatation  is  reached. 

When  the  stricture  is  not  pervious  from  the  bladder,  or  when  it  is  im- 


Fig.  299. — Operation  of  ureteroplasty  for  stricture 


SURGERY  OF  THE  URETERS 


573 


possible  to  pass  an  instrument  into  the  vesical  end  of  the  ureter,  the  narrow- 
ing may  be  attacked  from  above.  These  cases  are  always  complicated  by 
hydronephrosis;  hence  it  is  easy  to  enter  the  pelvis  of  the  kidney  through 
its  posterior  wall.  If  the  ureteral  orifice  of  the  pelvis  cannot  be  found,  the 
ureter  can  be  exposed  slightly  below  this  point,  opened  by  a  longitudinal 
incision,  and  explored  above  and  below  by  bougies  ranging  in  size  from  No.  4 
to  No.  12  French.  If  the  stricture  is  not  amenable  to  dilatation  (traumatic), 
it  may  be  treated  by  longitudinal  incision  and  transverse  union  of  the  re- 
sulting wound  (Fig.  299),  or  by  excision  and  the  restoration  of  the  con- 
tinuity of  the  ureter  by  uretero-ureterostomy.  If  none  of  these  procedures  are 
practicable,  the  ureter  may  be  divided  and  implanted  into  the  bladder  or 
on  the  skin  surface,  or  the  kidney  and  ureter  may  be  excised.  The  last 
operation  is  indicated  in  cases  of  unilateral  tuberculous  stricture. 

Klister,  finding  obliteration  of  the  ureter  three  centimetres  below  the  pelvis 
of  the  kidney,  resected  three  centimetres  of  the  ureter,  including  the  stric- 
tured  portion,  and  fastened  the  distal  end  to  the  lower  part  of  the  renal  pelvis. 
The  patient  was  cured. 

After  having  found  one  stricture,  the  ureter  should  always  be  sounded 
to  determine  the  presence  or  absence  of  others. 

CALCULUS  OF   THE  URETER 
The  great  majority  of  kidney-stones  either  remain  lodged  in  or  near  the 
pelvis  or,  having  once  entered  the  ureter,  pass  into  the  bladder.    This  passage 


\- 


Fig.  300. — Ureteral  calculi.  A,  ball  valve,  permitting  intermittent  flow 
of  urine;  B,  impacted,  causing  complete  blockage,  with  resultant  atrophy 
and  atresia  of  ureter  below;  C,  sacculated  stone,  permitting  passage  of 
urine  and  the  introduction  of  a  catheter. 


574 


GENITO-URINARY  SURGERY 


is  often  attended  by  no  symptoms.  When  the  stone  is  of  such  size  and  shape 
that  it  is  arrested  in  its  passage,  thus  blocking  the  ureter,  a  nephritic  colic 
develops.  Schenck  and  Tenney  note  that  of  one  hundred  and  thirty-four  cases 
of  ureteral  calculi  seventy-four  were  in  females  and  fifty-eight  in  males.  The 
points  of  impaction  correspond  to  the  points  of  narrowing  of  the  canal  (see 
p.  560).  About  one-quarter  are  lodged  at  the  first  point  of  narrowing.  A 
few  more  than  one-eighth  are  caught  at  the  middle  constriction,  and  over 
half  of  all  ureteral  calculi  become  impacted  just  above  the  bladder.  They  may 
lodge  in  the  intravesical  or  even  in  the  intramural  portion.  A  single  calculus  is 
the  rule  (Fig.  300),  but  in  about  one-eighth  of  the  cases 
they  are  multiple  (Figs.  301  and  302). 

Symptoms. — The  prodromal  symptoms  of  calculus  in 
the  ureter  may  be  those  of  renal  calculus  (see  p.  621)  or 
the  passage  of  gravel  and  small  concrements  with  the  urine. 
Often  the  attack  comes  on  without  prodromal  symptoms. 
The  patient  is  seized  suddenly  with  an  agonizing  pain 
radiating  over  the  lumbar  and  hypochondriac  regions, 
along  the  course  of  the  ureter,  to  the  end  of  the  penis,  to 
the  testicle  of  the  affected  side,  and  to  the  inner  surface 
of  the  thigh.  The  pain  is  usually  continuous,  with  exacer- 
bations. It  may  be  felt  in  the  belly,  small  of  the  back, 
or  sacrum;  very  exceptionally  it  is  referred  to  the  chest. 
The  suffering  is  so  severe  that  the  patient  becomes 
blanched,  bathed  in  cold  sweat,  and  sometimes  collapses. 
There  is  often  reflex  vomiting.  The  testicle  of  the  affected 
side  is  usually  drawn  close  up  to  the  external  ring,  and 
the  abdomen  may  become  tender  and  tympanitic;  if  there 
has  been  no  infection  of  the  kidney  pelvis,  fever  rarely 
develops.  There  is  often  a  constant  distressing  desire  to 
urinate,  with  loss  of  power  to  empty  the  bladder.  There 
may  be  anuria  due  to  reiiex  disturbance  of  the  healthy 
kidney,  perhaps  more  frequently  attributable  to  the  fact 
that  the  patient  is  possessed  of  but  one  secreting  kidney, 
the  duct  of  which  is  blocked. 

Pain  may  be  referred  to  the  healthy  kidney.  Neuman 
has  reported  three  cases  of  this  crossed  renal  pain,  in  two 
of  which  calculi  and  in  one  pyonephrosis  were  found  on  the  side  opposite  that 
which  gave  the  subjective  symptoms. 

The  pain  and  reflex  disturbances  are  due  to  retention  of  urine  in  the 
kidney  pelvis  and  the  upper  segment  of  the  ureter.  For  a  time  this  retention 
may  be  absolute,  since  the  irritation  and  congestion  incident  to  the  arrest  of 
the  stone  occasion  swelling  and  spasm  which  are  sufficient,  together  with  the 
foreign  body,  to  close  entirely  the  ureteral  lumen.  These  symptoms  may  last 
a  few  minutes,  a  few  hours,  or  several  days,  and  their  subsidence  may  be  as 
sudden  as  their  onset.  This  sudden  complete  subsidence  indicates  either  retro- 
gression of  the  stone  into  the  kidney  pelvis  or  its  extrusion  into  the  bladder- 


FlG.  301. — Multiple  cal- 
culi of  the  ureter.  (From 
Laboratory  of  Surgical- 
Pathology,  University  of 
Pennsylvania.) 


SURGERY  OF  THE  URETERS 


575 


cavity.  The  symptoms  may  subside  gradually,  recurring  at  intervals,  and 
may  be  followed  by  the  gradual  development  of  hydronephrosis.  This  indi- 
cates that  the  stone  has  been  lodged  in  the  ureter,  and  that  the  first  abso- 
lute obstruction  has  yielded,  partly  to  dilatation  of  the  foreign  body,  partly 


Fig.  302. — Multiple  ureteral  calculi.     (Skiagram  by  Dr.  H.  K.  Pancoast.) 

to  relaxation  of  the  spasm,  and  has  allowed  a  portion  of  the  urine  to  pass 
through.  Under  these  circumstances  kidney  colic  is  liable  to  recur,  but  with 
less  severity. 

During  an  attack  of  colic  the  urine  may  be  absolutely  normal.  This  points 
to  the  existence  of  one  healthy  kidney.  If  blood  is  found,  it  may  be  taken 
as  an   evidence   that  the  obstruction  is   not   complete,   provided   there  is  no 


576 


GENITO-URINARY  SURGERY 


reason  to  believe  that  the  hemorrhage  comes  from  the  kidney  or  the  ureter 
of  the  unaffected  side.  Immediately  on  the  subsidence  of  the  attack  a  small 
quantity  of  blood  is  constantly  found  in  the  urine. 

Diagnosis. — ^The  diagnosis  of  impacted  ureteral  stone  is  based  on  a  his- 


Fig.  303. — Calculus  in  pelvic  ureter.  A  collargol  skiagram  demonstrating  a  hydro- 
ureter  and  hydronephrosis  of  the  right  side  due  to  a  calculus  impacted  in  the  lower  end 
of  the  ureter.  The  calculus  was  pushed  up  the  ureter  about  three  inches  when  the  catheter 
was  introduced.  Seventy  cubic  centimetres  of  ten  per  cent,  collargol  were  injected  on 
the  right  side  before  pain  was  produced;  on  the  left  side  but  ten  cubic  centimetres  could  be 
injected.  Indigocaripin  was  eliminated  on  the  left  side  in  si-xteen  minutes;  on  the  right 
side  not,  for  over  twenty  minutes.     (Skiagram  by  Dr.  H.  K.  Pancoast.) 

tory  of  the  symptoms  of  kidney  calculus  (see  p.  621)  and  of  one  or  more 
attacks  of  colic,  followed  by  the  development  of  hydronephrosis  (Fig.  303), 
pyonephrosis,  or  pyelonephritis.  The  X-ray  will  often  demonstrate  both  the 
seat  and  the  number  of  ureteral  calculi.     When  the  shadows  are  not  placed 


SURGERY  OF  THE  URETERS  577 

along  the  normal  course  of  the  ureters,  the  presence  of  phleboliths  or  calcare- 
ous lymph-nodes  should  be  suspected.  For  the  positive  differentiation  of  ure- 
teral calculi  and  phleboliths  it  is  often  necessary  to  make  the  radiogram  with 
a  radiographic  catheter  in  the  ureter;  in  such  cases  it  is  best  to  make  stereo- 
scopic plates,  lest  a  phlebolith  lie  directly  in  line  with  the  catheter. 

Palpation  either  through  the  rectum  or  through  the  abdominal  walls, 
ureteral  catheterization,  and  the  X-ray  may  enable  the  surgeon  to  form  a 
positive  opinion  as  to  the  presence  of  ureteral  calculus;  but  it  must  be  con- 
fessed that  often  all  diagnostic  means  fail.  Thus,  a  clear  history  may  be 
wanting,  the  patient  perhaps  having  severe  abdominal  pain,  which  is  attrib- 
uted possibly  to  gall-stones  or  to  some  other  intra-abdominal  trouble.  If  the 
stone  completely  blocks  the  ureter,  in  place  of  hydronephrosis  the  kidney  may 
atrophy  exactly  as  it  would  do  if  a  ligature  were  applied  about  the  ureter. 
In  fat  subjects  it  is  difficult  to  develop  a  satisfactory  skiagram. 

Diagnosis  founded  on  kidney  colic  is  usually  fairly  reliable,  since  this 
pain  is  highly  characteristic.  Yet  it  must  be  remembered  that  stone  in  the 
ureter  has  been  diagnosed  when  the  real  condition  was  passage  of  a  gall- 
stone, appendicitis,  neuritis  of  the  lumbar  nerves,  spinal  caries,  or  acute  intesti- 
nal obstruction. 

Careful,  repeated  examinations  of  the  urine  will  usually  enable  the  surgeon 
to  determine  whether  or  not  the  symptoms  are  due  to  blocldng  of  the  ureter. 
Moreover,  the  conditions  with  which  ureteral  calculus  may  be  confounded 
have  usually  certain  pathognomonic  features  which  sooner  or  later  manifest 
themselves.  Thus,  gall-stone  is  attended  with  jaundice,  and  the  pain  is  likely 
to  be  referred  to  the  region  of  the  right  shoulder.  Appendicitis  exhibits  in- 
creasing tenderness  on  pressure  over  McBurney's  point,  the  abdominal  symp- 
toms become  rapidly  and  progressively  worse,  and  blood  and  pus  are  not  found 
in  the  urine.  In  neuritis  of  the  lumbar  nerves  the  tenderness  is  superficial, 
and  there  is  no  marked  change  either  in  the  quantity  of  urine  passed  or  in 
its  constituents.  The  persistent  vomiting  of  intestinal  obstruction,  shortly 
becoming  faecal,  and  the  obstinate  constipation,  would  suggest  the  nature  of 
the   affection. 

As  the  symptoms  are  due  to  obstruction,  and  not  to  the  irritation  caused 
by  the  rough  corners  of  a  stone,  they  will  be  as  distinctly  marked  if  the 
obstruction  is  due  to  a  portion  of  tumor,  a  blood-clot,  or  a  mass  of  inspissated 
tuberculous  pus.  The  diagnosis  as  to  the  cause  of  the  obstruction  is  dependent 
on  the  previous  history  of  the  patient. 

Intermittent  pyuria — that  is,  the  passage  of  normal  urine  during  attacks 
of  colic,  the  passage  of  pus  in  the  urine  during  intervals — points  to  the  exist- 
ence of  one  healthy  kidney.  The  blocking  during  the  acute  attacks  is  com- 
plete, hence  no  pus  escapes  into  the  bladder;  during  the  intervals,  owing  to 
relaxation  of  spasm  or  lessened  congestion,  part  of  the  urine  escapes  on  the  dis- 
eased side,  carrying  with  it  pus. 

Palpation  will  fail  certainly  in  a  large  majority  of  cases.  It  may,  however, 
show  a  point  of  tenderness,  which  if  constant  is  a  sign  of  some  value  in 
locating  the  stone.  If  the  calculus  is  lodged  near  the  vesical  orifice  of  the 
ureter,  it  may  readily  be  felt  in  women.  In  men  this  is  more  difficult,  since 
the  examining  finger  per  rectum  can  rarely  be  extended  as  far  as  the  posterior 


578  GENITO-URINARY  SURGERY 

extremity  of  the  seminal  vesicles.  Ureteral  catheterization  may  succeed  in 
locating  the  seat  of  obstruction,  and  may  possibly  indicate  the  presence  of 
stone.  In  order  to  demonstrate  the  fact  that  the  catheter  has  come  in  con- 
tact with  a  stone,  Kelly  has  advocated  the  use  of  catheters  whose  ends  have 
been  dipped  in  melted  paraffin,  and  Cunningham  and  others  have  devised 
styletted  catheters  with  devices  making  the  impact  of  the  catheter  against 
the  stone  audible.  As  a  further  means  of  diagnosis,  and  one  always  justi- 
fiable when  the  integrity  of  the  kidney-substance-  is  threatened  by  the  per- 
sistence of  symptoms,  exploration  by  lumbar  incision  is  valuable.  This  en- 
ables the  surgeon  to  explore  directly  the  entire  abdominal  ureter,  and  by 
means  of  bougies  to  determine  whether  or  not  the  pelvic  portion  is  patulous. 

The  diagnosis  betwen  ureteral  calculus  and  blocking  of  the  ureter  from 
unnatural  mobihty  of  the  kidne}^  is  sometimes  absolutely  impossible  except 
by  pyelograph}^  (radiography).  The  symptoms  are  precisely  the  same,  and  in 
both  cases  the  urine  may  show  blood  after  the  attack  is  over.  A  movable  kid- 
ney would  be  suggested  b}"  the  prompt  relief  which  sometimes  follows  either 
abdominal  manipulation  of  the  organ  or  the  assumption  of  the  dorsal  decubitus. 

Much  valuable  information  is  often  obtained  by  observing  the  elimination 
of  indigocarmin  by  the  suspected  kidney  as  compared  with  that  of  its  mate. 
As  ureteral  calculi  commonly  cause  deterioration  of  the  renal  parenchyma  by 
reason  of  the  back  pressure  exerted,  when  other  symptoms  point  to  the  exist- 
ence of  this  condition  delayed  elimination  is  strongly  corroborative  evidence. 

The  diagnosis  of  ureteral  calculus  can  rarely  be  estabhshed  from  a  single 
symptom  or  sign,  but  with  the  newer  methods 'of  examination  at  our  disposal, 
and  the  marked  improvements  in  some  of  the  older  ones  which  have  been 
made  during  the  last  few  years,  failure  to  arrive  at  a  diagnosis  by  non- 
operative  means  is  almost  as  rare. 

Prognosis. — The  calculus  ha\dng  passed  into  the  ureter  may  recede  into 
the  kidney  pelvis,  may  pass  on  to  the  bladder,  or  may  be  permanently  lodged. 

Calculus  lodged  in  the  ureter,  if  it  entirely  blocks  this  canal,  causes  rapid 
and  complete  destruction  of  the  secreting  substance  of  the  kidney.  Provided 
the  other  kidney  is  healthy,  it  is  usually  able  to  function  for  both.  When  the 
obstruction  is  partial  there  is  back  pressure,  with  more  or  less  dilatation  of 
the  ureter,  kidney  pehis,  and  calices,  and  gradual  degeneration  of  the  kidney- 
substance.  The  congestion  incident  to  this  condition  strongly  predisposes  to 
infection.     As  the  ureteral  walls  dilate  they  commonly  become  thickened. 

The  calculus  maj'  become  sacculated  to  one  side  of  the  ureteral  lumen, 
so  that  there  is  little  interference  to  the  passage  of  urine  or  the  ureteral  cath- 
eter (Fig.  304),  or  it  ma}^  ulcerate  entirely  through  the  ureteral  wall,  forming 
an  abscess,  which  may  open  externally  in  the  lumbar  region,  or  into  the  colon, 
or  may  follow  the  course  of  perinephritic  abscesses. 

Treatment. — Since  most  stones  which  enter  the  ureter  from  the  kidney 
pelvis  pass  into  the  bladder,  the  immediate  treatment  of  either  a  first  agoniz- 
ing attack  of  renal  colic  incident  to  calculous  obstruction  of  the  ureter,  or  of 
recurrent  mild  attacks,  should  be  palliative,  measures  being  promptl}^  taken, 
however,  to  determine  by  X-ra}^  the  size  and  position  of  the  stone.  The  patient 
should  be  given  a  hot  bath,  and  a  full  dose  of  morphine  hypodermically. 
The  administration  of  medicines  by  the  mouth  is  of  little  service,  since  there 


SURGERY  OF  THE  URETERS  579 

i 
is  usually  vomiting.  A  hot  rectal  enema  is  useful  in  relieving  the  tympany^, 
which  is  sometimes  symptomatic  of  ureteral  obstruction.  When  the  pain 
is  so  agonizing  that  it  seriously  affects  the  pulse,  inhalations  of  ether  should 
be  given  until  sufficient  time  has  elapsed  for  the  morphine  to  produce  its 
quieting  effect.  The  urgent  desire  to  micturate,  from  which  patients  suffering 
from  kidney  colic  complain,  is  a  pure  reflex.     There  is  usually  retention, 


Fig.  304. — Calculus  sacculated  in  wall  of  left  ureter.     (Skiagram  by  Dr.  H.  K.  Pancoast.) 


probably  spasmodic  in  nature.  It  is  relieved  by  a  hot  sitz-bath,  the  patient 
being  directed  to  urinate  while  sitting  in  the  bath.  If  it  should  persist,  the 
bladder  forming  a  distinct  tumor  above  the  pubis,  the  catheter  should  be 
used  with  every  aseptic  precaution,  since  the  conditions  for  ascending  infec- 
tion are  peculiarly  favorable  during  and  after  the  passage  of  a  stone. 

When  it  is  evident  from  the  size  of  the  stone  as  shown  by  the  X-ray, 
or  from  the  gradual  develooment  of  a  hydronephrosis,  or  the  persistently  re- 
currins:  mild  attacks  of  kidney  colic,  that  a  calculus  is  lodged,  and  that  the 
kidney  is  becoming  seriously  affected;  when  during  an  acute  attack  the  secre- 


580 


GEXITO-URIXARY  SURGERY 


tion  of  the  urine  is  partly  or  completely  suppressed,  suggesting  that  the 
patient  has  not  a  healthy  kidney  on  which  to  fall  back;  or  when  fever  and 
hectic  develop,  together  \s-ith  pus  in  the  urine,  pointing  to  pyonephrosis, — 
surgical  interference  is  imperative. 

Calculi  lodged  in  the  vesical  orifice  of  the  ureter  and  projecting  into  the 
bladder  have  been  removed  by  the  lithotrite  or  by  cystoscopic  forceps,  or 
through  a  vesical  opening.  Small  stones  lodged  near  the  lower  end  of  the 
ureter  can  sometimes  be  made  to  pass  by  dilating  the  ureteral  orifice  by  the 
passage  of  a  Garceau  dilating  catheter  or  some  other  form  of  ureteral  dilator, 
and  injecting  sterile  olive  oil,  from  five  to  fifteen  cubic  centimetres,  about 
the  stone.  In  women  calculi  frequently  lodge  in  the  portion  of  the  ureter 
h'ing  within  the  folds  of  the  broad  ligament,  because  of  narrowing  incident  to 

! "         '  •  "^  disease  of  the  structure.    An  incision  through 

■    ■  •  the  anterior  vaginal  vault  upon  such  a  stone, 

if  it  be  palpable,  enables  the  surgeon  to  re- 
move it  -n-ithout  opening  either  the  peritoneum 
or  the  bladder. 

The  operative  approach  for  the  removal 
of  calculi  from  the  ureter  varies  with  the  part 
of  the  canal  in  which  the  stone  has  lodged,  as 
determined  by  the  ureteral  catheter  and  the 
X-ray.  In  the  first  three  or  four  inches  of  its 
course  the  incision  is  a  slight  prolongation  of 
the  oblique  cut  used  for  the  exposure  of  the 
kidney.  Farther  do-v^m  the  ureter  is  better 
reached  through  a  muscle-splitting  incision: 
this  may  be  placed  at  any  level  be^ow  that  of 
the  umbilicus,  according  to  the  position  at 
which  the  stone  has  been  halted.  The  skin 
cut,  about  five  inches  long,  is  made  either  in 
the  direction  of  the  fibres  of  the  external  oblique,  or  almost  transversely  across 
the  body,  in  the  line  of  skin-cleavage.  The  muscles  are  split  in  the  direction  of 
their  fibres,  being  torn  rather  than  cut.  The  wound  thus  made  is  -viddely  separated 
by  means  of  three  or  four  retractors,  and  the  peritoneum  is  striooed  from  the 
parietes  and  retracted  toward  the  midline.  The  ureter  is  adherent  to  the  peri- 
toneum, so  that  it  is  to  be  searched  for  upon  this  membrane,  not  on  the  structures 
of  the  body- wall,  over  which  it  normally  lies,  ^^^len  the  stone  is  in  the  extreme 
lower  end  of  the  ureter  it  is  most  convenient,  when  possible,  to  work  it  up 
the  canal  with  the  fingers  till  it  is  in  a  more  easily  accessible  portion.  Strands 
of  hea\y  silk  should  then  be  passed  about  the  ureter  above  and  below  the 
stone  to  prevent  its  escape,  and  a  longitudinal  incision  made  of  sufficient  size 
to  effect  its  delivery.  The  cut  is  closed  wnth  one  or  more  sutures  of  fine  catgut 
passed  through  the  fibrous  and  muscular  coats,  or.  if  this  is  difficult  or  imoos- 
sible,  the  wound  may  be  left  open.  The  wound  in  the  parietes  is  closed  about 
a  cigarette  drain  passed  do\\Ti  to  the  ureteral  incision;  the  drain  is  to  be 
removed  about  the  third  day  after  operation    (Tie.  305). 

Calculi  lodged  in  the  pelvic  portion  of  the  ureter  can  be  reached  through 
the  lower  half  of  the  ilio-lumbar  incision  or  through   a  vertical   cut   carried 


L 

Fig.   305. — Muscle  sp'itti-s  incision  for  the 
exposure  of  the  ureter. 


SURGERY  OF  THE  URETERS  581 

from  the  insertion  of  the  rectus  muscle  four  inches  upward  (Witherspoon). 
The  muscle  is  torn  through  in  the  direction  of  the  fibres  and  the  fascia  is  cut, 
exposing  the  peritoneum,  which  is  stripped  up  from  the  abdominal  wall  as 
far  as  the  ilio-pectineal  line.  The  finger  is  then  passed  to  the  vesical  base, 
pushing  upward  and  inward  the  lateral  false  ligament  of  the  bladder,  and 
separating  the  peritoneum  from  the  pelvic  wall  as  far  back  as  the  vas  deferens; 
by  following  this  canal  for  two  inches  from  its  point  of  crossing  the  obturator 
vessels,  the  ureter  will  be  reached  passing  behind  it.  Both  these  canals  strip 
up  with  the  peritoneum.  The  ureter  may  be  palpated  as  far  as  the  brim  of 
the  pelvis.    The  operation  is  bloodless  and  leaves  a  strong  abdominal  wall. 

The  mortality  of  uretero-lithotomy  when  uncomplicated  by  anuria,  pyelitis, 
or  pyelonephrosis  is  less  than  six  per  cent. 

FISTULA  .OF  THE  URETER 

Fistulae  are  secondary  to  wounds,  rupture,  or  ulceration  of  the  ureters.  A 
longitudinal  wound  will  usually  heal  spontaneously  without  the  formation  of 
either  fistula  or  stricture;  transverse  wounds  involving  half  the  diameter  of  the 
ureter,  and  particularly  when  they  completely  sever  it,  are  followed  by  fistulse. 

The  wounds  are  usually  inflicted  during  the  course  of  gynaecological  opera- 
tions. Spontaneous  fistula — i.e.,  that  due  to  ulceration — is  caused  by  tuber- 
culous infiltration,  malignant  growth,  calculus,  or  foreign  body;  the  fistula 
under  such  conditions  is  secondary  to  partial  or  complete  ureteral  obliteration. 

A  fistula  may  open  on  the  surface  of  the  body  or  into  the  cavity  of  a 
neighboring  viscus.  The  surface  opening  is  commonly  in  the  lumbar  region; 
it  may  be  found  in  the  groin  or  in  some  portion  of  the  anterior  abdominal 
parietes.  Visceral  opening  is  commonly  into  the  uterus  or  vagina,  but  may  be 
into  the  rectum,  and  very  exceptionally  into  the  stomach.  The  patulous  tract 
is  apt  to  be  fairly  direct;  it  may  be  long  and  irregular. 

Symptoms. — The  invariable  symptom  of  ureteral  fistula  is  a  continuous 
or  intermittent  discharge  of  urine.  Duplay  and  Reclus  state  that  if  the  fistula 
is  near  the  kidney  the  flow  of  urine  is  continuous.  If  it  is  low  down  towards 
the  vesical  extremity  the  flow  is  intermittent,  coming  in  jets.  The  urine  may 
remain  perfectly  clear,  showing  no  admixture  of  pus  or  kidney  albumen.  For 
diagnostic  purposes  methylene  blue  may  be  given  by  the  mouth. 

Diagnosis. — The  diagnosis  between  ureteral  and  vesical  fistulae  can  be 
established  by  injecting  colored  fluids  into  the  bladder.  Renal  fistulae  are 
fairly  direct,  and  but  a  slight  amount  of  urine  escapes  from  them  if  -the  ureter 
is  pervious.  Catheterization  of  the  ureter  and  injection  of  colored  fluid  will 
sometimes  be  serviceable  in  establishing  a  diagnosis. 

Prognosis. — There  is  little  tendency  towards  spontaneous  cure  of  ureteral 
fistula.  Provided  narrowing  of  the  orifice  does  not  take  place,  the  fistula  may 
produce  no  appreciable  effect  upon  the  general  health.  It  often  happens  that, 
because  of  gradual  cicatricial  formation  and  encroachment  upon  the  ureteral 
calibre,  hydronephrosis  develops.  It  should  be  remembered  that  in  case  the 
ureter  is  entirely  divided,  the  lower  extremity  becomes  atrophic  from  disuse, 
thus  making  an  operation  for  the  restoration  of  the  continuity  of  the  channel 
•extremely  difficult. 


582  GEXITO-URIXARY  SURGERY 

Treatment. — The  first  requisite  of  successful  treatment  is  that  the  ureter 
shall  be  restored  to  its  normal  calibre.  It  is  possible  that  this  may  be  accom- 
plished by  the  use  of  ureteral  bougies  or  continuous  ureteral  catheterization 
practised  through  tlie  bladder.     Usually  the  ureter  is  impermeable. 

^Mien  the  fistula  opens  into  the  vagina,  colpocleisis  may  be  performed. 
This  operation,  first  practised  by  Hahn,  converts  a  part  of  the  vagina  into 
an  artificial  reservoir  for  the  urine.  Kelly  in  one  case  of  uretero-vaginal  fistula 
closed  the  ureter  by  suture.  When  the  vesical  extremity  of  the  canal  is 
obliterated  the  ureter  may  be  implanted  into  the  bladder  b}^  the  intraperitoneal 
or  the  extraperitoneal  route. 

^Mien  the  fistula  involves  the  abdominal  portion  of  the  ureter,  direct 
closure,  splitting  of  the  ureter  and  transverse  suture,  or.  excision  of  the  dis- 
eased area,  followed  by  ureterostomy,  may  be  indicated.  When  it  is  placed 
high  in  the  .ureter,  it  may  be  resected,  together  vnih.  a  segment  of  the  ureter, 
and  this  canal  may  be  sutured  to  the  renal  pelvis. 

Cure  is  assured  by  nephrectomy.  This  operation  has  been  many  times 
successfully  performed.  It  should,  however,  be  left  as  a  last  resort,  efforts 
being  made  either  to  restore  the  continuity  of  the  ureter  or  to  implant  it  into 
the  bladder. 

TUBERCULOSIS  OF  THE  URETER 

Tuberculous  involvement  of  the  ureter  is  usually  secondary  to  tuberculous 
disease  of  the  bladder  or  the  kidney.  The  infiltration  attacking  a  portion 
of  the  ureter  and  partially  or  completely  obliterating  it  may  produce  dilatation 
of  the  segment  above,  and  hydronephrosis  or  pyonephrosis;  or  the  entire  ureter 
may  be  infiltrated,  becoming  a  dense,  often  nodular,  impervious  cord. 

The  symptoms  of  tuberculous  infiltration  of  the  ureter  are  usually  com- 
pletely masked  by  those  of  vesical  or  renal  disease.  In  women  palpation  of 
the  lower  extremity  of  the  ureter  through  the. vaginal  vault  may  show  char- 
acteristic induration  and  nodulation,  and  in  thin  individuals  the  tube  can  some- 
times be  felt  as  it  passes  over  the  pelvic  brim  as  an  indurated  cord  the  size 
of  a  lead-pencil.  In  both  sexes  attempts  at  ureteral  catheterization  demonstrate 
points  of  narrowing;  the  ureteral  orifices  are  rigid,  the  so-called  "golf-hole"  type. 

The  treatment  of  ureteral  tuberculosis  cannot  be  formulated,  since  this 
is  never  encountered  clinically  as  an  isolated  lesion.  If  in  the  course  of  nephrec- 
tomy for  tuberculous  kidney  the  ureter  is  found  involved,  it  should  be  removed 
with  the  kidney  (see  p.  658). 

TUMORS  OF  THE  URETER 

Primary  tumors  of  the  ureter  are  less  common  than  secondary  growths, 
the  mother-growths  of  which  lie  in  the  kidney  pelvis  or,  in  occasional  instances, 
in  the  bladder.  Cysts,  fibromata,  and  myomata  have  been  reported;  papil- 
lomata,  benign  from  a  pathological  standpoint,  but  clinically  malignant,  have 
been  most  frequently  encountered;  instances  of  primary  carcinoma  and  sar- 
coma have  been  noted,  and  many  cases  of  secondary  carcinomatous  involve- 
ment are  on  record. 

Hydronephrosis  and  pyonephrosis  are  frequent  complications.  Metastasis 
may  take  place  to  the  bladder,  kidney,  liver,  retroperitoneal  lymph-nodes,  or 
pleura. 


SURGERY  OF  THE  URETERS  583 

Symptoms. — These  are  not  distinctive.  Blood  has  been  present  in  about 
eighty  per  cent,  of  cases  and  is  often  the  first  symptom;  pain  and  the  pres- 
ence of  a  demonstrable  tumor  are  present  in  about  sixty  to  seventy  per  cent, 
of  cases,  the  pain  being  that  of  ureteral  obstruction. 

Occasionally  the  growth  protrudes  into  the  bladder  from  the  ureteral  ori- 
fice, or  fragments  are  detached  and  recovered  from  the  urine.  It  is  only  in 
such  cases  that  a  positive  diagnosis  is  possible. 

Treatment. — Nephro-urectomy  is  the  only  operation  to  be  considered.  In 
some  cases  it  is  necessary  to- include  a  portion  of  the  bladder  in  the  resection. 

PROLAPSE   OF  THE  URETER 

has  been  reported  by  Caile  in  a  child  two  weeks  old.  There  are  nineteen 
reported  cases,  two  of  whom  were  operated  on,  with  one  death.  (Young.) 
A  sac  which  was  supposed  to  be  a  vesical  diverticulum  presented  at  the  urethral 
orifice.  It  was  found  to  be  a  prolapsed  ureter  dragged  down  by  a  papillomatous 
growth. 

Two  cases  of  ureteral  cyst  caused  by  psorosperms  have  been  reported, 
one  by  Eve;  the  only  symptom  was  profuse  hsematuria,  which  was  not  attrib- 
uted to  the  cystic  formation.    . 


CHAPTER  XXVI       " 

SURGERY  OF  THE  KIDNEYS 

SURGICAL  ANATOMY 

The  kidneys  are  situated  in  the  hypochondriac  regions  on  either  side  of  the 
vertebral  column  behind  the  peritoneum.  (Plate  IX.)  The  right  kidney  is 
a  httle  lower  than  the  left  (three-quarters  of  an  inch),  probably  because  of  the 
superimposed  liver.  The  left  kidney  extends  from  the  level  of  the  interval 
between  the  eleventh  and  twelfth  ribs,  near  the  spine,  to  the  level  of  the  third 
lumbar  spine.  Each  organ  is  inclined  forward  and  inward,  so  that  their  upper 
portions  converge.  The  outer  borders  face  upward  and  backward,  the  inner 
downward  and  forward. 

The  kidne3^s  are  fixed  in  position  by  a  series  of  short  blood-vessels,  the 
parietal  peritoneum,  the  pressure  of  the  abdominal  viscera,  and  a  fibro-lipomatous 
sheath  called  the  renal  fascia.  This  fascia  is  formed  by  a  splitting  of  the 
subperitoneal  connective  tissue.  It  encloses  the  kidney  in  a  pocket  opening 
below  and  passes  inward  as  a  single  layer  to  cover  the  great  blood-vessels. 
During  foetal  life  this  investment  is  purely  fibrous;  later  there  is  an  abundant 
deposit  of  fat,  to  which  the  name  of  fatty  capsule  has  been  given.  The  deposit 
of  fat  is  most  marked  on  the  outer  borders  and  posterior  surfaces  of  the  kid- 
neys. It  may  be  one  or  two  inches  in  thickness,  and  serves  to  fix  the  organs 
in  a  soft  nidus. 

The  kidney  of  average  size  is  four  and  a  half  inches  long,  two  and  a  half 
inches  broad,  and  one  and  a  half  inches  thick.  It  weighs  about  four  and  a  half 
ounces.  The  left  kidney  is  often  slightly  larger  than  the  right.  The  kidneys  of 
women  are  about  half  an  ounce  lighter  than  those  of  men. 

It  is  irregularty  oval  in  shape,  with  a  convex  outer  border  and  a  concave 
inner  border.  It  is  ordinarily  of  brownish-red  color,  but  this  is  subject  to 
marked  variations,  depending  upon  the  degree  of  congestion  and  the  presence 
of  degenerations.  It  is  fairly  firm  in  consistence.  The  anterior  surface  of  the 
kidney,  turned  fon\-ard  and  slightly  outward,  is  covered  by  peritoneum  in  its 
lower  portion.  The  upper  extremities  of  both  kidneys  are  capped  by  the 
suprarenal  bodies. 

The  Hver  lies  in  front  of  the  upper  two-thirds  of  the  right  kidney,  and 
is  often  attached  to  it  by  a  peritoneal  fold  called  the  hepatorenal  ligament.  Its 
lower  third  is  in  relation  with  the  ascending  colon,  which  lies  in  direct  contact 
with  it,  the  beginning  of  the  transverse  colon,  and  the  second  portion  of  the 
duodenum,  which  descends  vertically  along  the  inner  portion  of  the  anterior 
surface,  crossing  the  renal  vessels  and  their  bifurcations  at  a  right  angle.  The 
inferior  vena  cava  obliquely  crosses  the  extreme  upper  portion  of  the  right 
kidney.     fTestut.) 

The  anterior  surface  of  the  left  kidney  is  in  relation  ^dth  the  tail  of  the 
584 


PLATE  IX. 


I    \  /      : 


Position  and  relation  of  the  kidneys  and  other  retroperitoneal  structures, 
r.  and/.  Right  and  left  kidney,     m.  Right  ureter.     6.  Bladder. 


SURGERY  OF  THE  KIDNEYS  585 

pancreas,  which  rests  upon  its  upper  fourth,  with  the  spleen  lying  above  and 
externally,  and  the  stomach  below.  The  terminal  portion  of  the  transverse 
colon  and  the  upper  portion  of  the  descending  colon  lie  directly  in  contact 
with  its  lower  half  or  two-thirds,  connected  to  it  by  loose  areolar  tissue,  unless 
there  be  a  distinct  mesocolon. 

The  comparatively  fiat  posterior  kidney  surface  faces  backward  and  in- 
ward. Behind  it  lie  the  diaphragm,  the  quadratus  lumborum  muscle,  from 
which  it  is  separated  by  the  anterior  layer  of  the  lumbar  fascia,  and  the  inter- 
costal and  lumbar  nerves,  and  to  the  inner  side  of  the  psoas  muscle.  Ex- 
ternally it  extends  beyond  the  quadratus  lumborum  muscle,  and  is  then  in 
relation  with  the  transversalis.  The  posterior  kidney  surface  is  entirely  free 
from  peritoneal  investment,  except  in  the  anomalous  condition  characterized 
by  the  presence  of  a  mesonephron. 

The  diaphragm  immediately  behind  the  upper  posterior  surface  of  the 
kidney  is  extremely  thin,  and  presents  a  triangular  opening,  allowing  the 
kidney  to  lie  in  almost  immediate  contact  with  the  pleura.  This  opening 
explains  the  frequency  with  which  abscesses  burrow  into  the  pleura.  The 
outer  convex  border  of  the  kidney  is  in  relation  with  the  spleen  and  descending 
colon  on  the  left  side,  the  liver  on  the  right  side.  The  inner  concave  border, 
resting  on  the  psoas  muscles,  presents  a  fissure  termed  the  hilum,  the  point 
of  entrance  and  exit  of  the  blood-vessels  and  ureter;  it  is  about  two  inches 
from  the  median  line  of  the  body,  and  is  about  one  and  a  half  inches  in 
depth.  The  important  structures  coming  off  from  it  are  the  veins,  placed 
anteriorly,  the  arteries,  behind  the  veins,  and  the  pelvis  and  ureter,  posteriorly. 
The  renal  arteries  and  veins  are  on  a  level  with  the  space  between  the  spines 
of  the  first  and  second  lumbar  vertebrae.  The  hilum  extends  to  a  consider- 
able depth  within  the  substance  of  the  kidney,  forming  a  central  cavity  known 
as  the  sinus. 

The  kidney  is  enclosed  in  a  proper  capsule  of  fibrous  tissue,  beneath  which 
lies  an  investment  of  unstriped  muscle.  The  solid  part  of  the  organ  is  com- 
posed of  the  cortical  layer,  containing  the  Malpighian  glomeruli,  which  are 
the  beginnings  of  the  uriniferous  tubules,  and  the  medullary  layer,  contain- 
ing the  straight  and  spiral  portions  of  the  uriniferous'  tubules,  as  well  as  the 
collecting  tubules.  These  collecting  tubules  are  arranged  ir  separate  pyramidal 
masses,  the  pyramids  of  Malpighi,  the  apices  of  which  form  papillae  project- 
ing into  the  sinus  (Fig.  306).  They  are  separated  from  each  other  by  the 
cortical  substance,  which  envelops  them  on  all  sides,  except  in  the  region  of 
the  papillae.  The  papillae  project  into  the  calyces  or  infundibula,  which  are 
small  diverticula  into  which  the  ureter  subdivides.  When  the  ureter  reaches 
the  sinus,  having  passed  in  by  the  hilum,  it  dilates  into  a  funnel-shaped  sac, 
called  the  pelvis.  From  this  sac  pass  a  few  major  channels,  each  of  which 
divides  into  several  smaller  ones,  the  calyces,  these  in  turn  terminating  about 
the  openings  of  the  papillae  (Fig.  307).  Usually  the  calyces  are  as  numerous 
as  the  papillae;  sometimes  two  papillae  open  into  a  single  tubule.  The  number 
of  calyces  is  usually  from  eight  to  twelve.  Each  is  about  two-fifths  of  an 
inch  long,  and  is  in  calibre  No.  6  to  No.  10  F.  Several  of  these  small  canals 
unite  to  form  a  series  of  three  or  four  larger  canals,  which  open  into  the  pelvis 
of  the  kidney  (Fig.  307).     There  are  usually  three  of  these  large  branchings 


586 


GENITO-URINARY  SURGERY 


of  the  .pelvis,— an  upper,  a  median,  and  a  lower.  They  vary  greatly  in  length 
and  calibre.  The  pelvis,  which  receives  the  urine  from  the  calyces,  is  about  an 
inch  high  and  not  quite  an  inch  wide,  and  runs  directly  into  the  ureter  (Fig. 
307).  Sometimes  the  junction  of  these  two  channels  is  marked  by  a  slight 
constriction.  The  pelvis  is  placed  within  the  sinus,  but  extends  inward  beyond 
the  limits  of  this  opening.  In  front  of  it  lie  the  vessels;  behind  it  lies  the 
posterior  renal  artery,  when  this  vessel  is  present.  The  portions  which  extend 
beyond  the  kidney  have  the  peritoneum  and  the  fatty  capsule  in  front,  the 
psoas  muscle  posteriorly.  The  duodenum  is  in  relation  with  the  anterior  surface 
of  the  right  pelvis. 

The  arteries  of  the  kidneys  divide  into  four  or  five  branches,  which  enter  the 


Fig.  306. — Longitudinal  section  of  right  kidney, 
showing  relations  of  pelvis  and  its  divisions 
to  renal  substance  and  to  sinus.  _  (Piersol's 
Anatomy.) 


Fig.  307. — Renal  pelvis  dis- 
sected from  the  pyramids.  P, 
pelvis;    U,    ureter.      (Henle.) 


hilum  and  lie  between  the  renal  vein  and  the  ureter.  Within  the  sinus  the 
branches  of  the  artery  run  beside  the  calyces  (infundibula)  and  are  embedded 
in  fat.  The  right  renal  artery  is  slightly  longer  than  the  left,  as  it  has  to  cross 
the  vertebral  column;  for  a  similar  reason  the  left  renal  vein  is  longer  than  the 
right.  The  renal  veins  leave  the  kidneys  at  the  hilum,  and,  passing  in  front 
of  the  renal  arteries,  empty  into  the  vena  cava;  the  spermatic  vein  joins  the 
renal  vein  on  the  left  side. 

The  blood-supply  to  the  kidneys  is  particularly  abundant.  The  renal  artery 
may  pass  as  a  single  vessel  to  the  hilum,  or  may  divide  into  several  branches 
before  reaching  this  point.  These  branches  are  named,  according  to  their  dis- 
tribution, superior,  middle,  and  inferior.  The  posterior  branch  passes  downward 
and  backward  to  enter  the  hilum  behind  the  pelvis. 

According  to  Bonney,  there  is  a  variance  in  the  renal  arteries  and  in  the 
arrangement  of  the  constituents  of  the  renal  pedicle  from  that  usually  de- 


SURGERY  OF  THE  KIDNEYS  587 

scribed  in  a  very  considerable  percentage  of  cases.  Among  fifty-nine  bodies 
examined  there  were  nineteen  in  which  multiple  arteries  passed  from  the  aorta 
to  one  or  both  kidneys.  These  vessels  usually  arose  side  by  side;  in  a  few 
instances  one  of  the  vessels  sprang  from  the  region  of  the  bifurcation.  The 
point  of  entrance  into  the  kidney  was  usually  the  hilum  or  one  of  the  poles,  but 
occasionally  the  anterior  surface  or  the  external  border.  Among  the  subjects 
examined  instances  were  found  in  which  arteries  lay  in  front  of  the  veins,  or 
behind  the  ureters. 

The  veins  are  proportionally  as  numerous  and  large  as  the  arteries.  In 
the  sinus  there  are  a  number  of  branches,  usually  lying  in  front  of  the  arteries; 
these  fuse  into  the  renal  vein.  This  is  a  short,  valveless  trunk  passing  to  the 
vena  cava.  The  perinephric  veins  are  large  and  numerous  and  communicate 
with  the  blood-vessels  of  the  kidney.  Hyrtl  has  demonstrated  that  about  two- 
thirds  of  all  kidneys  are  vascularized  by  two  distinct  vascular  systems,  the  ves- 
sels as  they  enter  being  separated  from  each  other  at  the  renal  pelvis.  The 
major  vascular  tree  occupies  about  three-fifths  of  the  kidney,  usually  its  anterior 
portion,  and  the  remaining  posterior  two-fifths  is  vascularized  by  the  minor 
system.  Normally  these  two  vascular  systems  are  separated  in  the  kidney  by  a 
distance  of  about  two  millimetres.  Upon  distention  of  the  pelvis  and  calyces, 
however,  this  separation  may  be  increased  considerably.  At  the  plane  of  sepa- 
ration no  large  vessels  are  found  and  none  cross.  Anastomoses  are  not  found 
in  the  kidney. 

The  lymphatics  pass  to  the  nodes  of  the  lumbar  plexus  lying  near  the 
hilum.  The  nerves  are  abundant  and  supplied  with  ganglia;  they  come  from 
the  sympathetic  system. 

Upon  careful  examination  the  surface  of  the  kidney  is  seen  to  be  made  up 
of  a  number  of  irregular  areas  about  the  size  of  the  end  of  the  thumb.  The 
areas  represent  the  bases  of  the  renal  pyramids.  They  are  surrounded  by  pale 
lines  representing  the  columns  of  Bertini  extending  up  between  the  pyramids 
and  forming  support  for  the  blood-vessels.  (Sometimes  these  pale  lines  are 
not  seen,  but  in  their  place  may  be  distinguished  groups  of  stellate  vessels.) 
These  small  white  lines  unite  a  little  anteriorly  to  the  convex  border  of  the 
kidney  into  a  longitudinal  slightly  depressed  white  line,  appropriately  called 
Brodel's  line,  which  represents  the  line  of  division  between  the  anterior  and 
posterior  rows  of  pyramids,  the  connective  tissue  of  which  carries  the  largest 
blood-vessels  (Fig.  308).  The  least  vascular  plane  is  usually  entered  by  incising 
the  surface  of  the  kidney  one  centimetre  back  of  this  line  and  cutting  toward 
the  pelvis  (Fig.  309). 

PHYSIOLOGY 

The  functions  of  the  kidney  are  the  excretion  of  the  urine,  and  probably 
the  elaboration  of  an  internal  secretion. 

The  excretion  of  the  urine  is  generally  believed  to  be  accomplished  in  the 
following  manner:  Both  secretion  and  filtration  participate,  the  former  being 
the  more  important.  Water  and  inorganic  salts  are  largely  eliminated  by  the 
glomeruli.  These  structures  seem  to  be  specially  constructed  to  act  as  filters, 
yet  it  seems  probable  that  even  here  the  epithelial  capsule  covering  the  tufts  of 
capillaries  has  a  distinct  selective  or  secretory  power.     The  epithelium  of  the 


588 


GENITO-URINARY  SURGERY 


SURGERY  OF  THE  KIDNEYS 


589 


convoluted  tubules  excretes  chiefly  the  organic  urinary  constituents;  it  may 
also  have  the  function  of  reabsorbing  some  of  the  water  excreted  by  the  glo- 
meruli. The  kidney  has  the  power  of  excreting  bacteria,  but  by  what  portions 
of  the  organ  these  are  extruded  we  are  ignorant. 

No  secretor}'  nerves  to  the  kidney  have  been  discovered.  There  are,  how- 
ever, numerous  vasomotor  fibres,  and  the  action  of  these  has  a  marked  influence 
on  the  activity  of  the  organ;  a  free  passage  of  blood  through  the  kidney,  as 
when  the  vessels  are  dilated,  is  much  more  favorable  to  renal  activity  than  an 
increment  in  arterial  pressure.  Yet  in  general  terms  diuresis  is  favored  by  an 
increase  in  the  systemic  pressure;  it  is  decreased  in  collapse,  and  is  abolished 
when  the  pressure  falls  to  about  40  mm.  of  mercun.-. 

Diuretics  probably  act  directly  on  the  renal  epithelium,  except  when  their 


Correct  I'neLs/'on 
.Incorrect     •• 


IVhil-e   li„t 


Major  ealy* 


Fig.  309. — Diagram  showing  location  of  nephrot- 
omy incision. 


Fig.  310. — Supernumerary  kidneys.  (Speci- 
men from  the  Mutter  Museum,  College  of  Physi- 
cians, Philadelphia.; 


influence  is  exerted  through  changes  in  the  general  circulation.  According  to 
the  experiments  of  Oliver,  Schafer,  Herring,  and  others,  there  is  a  diuretic 
principle  in  the  secretion  of  the  posterior  lobe  of  the  pituitar\'  gland.  ''  In- 
travenous injections  of  saline  extract  of  the  infundibular  part  of  the  pituitar\' 
body  produce  dilatation  of  the  kidney  vessels,  accompanied  by  increased  flow  of 
urine;  i.e.,  the  extract  has  a  diuretic  action.  With  the  first  injection  this  result 
is  accompanied  by  a  rise  of  blood-pressure  and  contraction  of  the  systemic 
arteries."  Subsequent  injections  have  the  same  diuretic  action,  but  usually  do 
not  raise  the  blood-pressure.  Verv-  large  doses,  by  causing  renal  vasoconstric- 
tion, may  lessen  diuresis  (Schafer  and  Herring). 

The  probability  of  the  existence  of  an  internal  secretion  rests  on  the  ob- 
servation that,  while  death  follows  the  removal  of  approximately  three-fourths 
of  the  renal  parenchyma,  removal  of  a  slightly  smaller  amount  may  be  followed 
by  an  elimination  of  water  and  urea  even  in  excess  of  the  normal,  and  on  the 


590  GENITO-URINARY  SURGERY 

prolongation  of  the  life  of  nephrectomized  dogs  by  the  injection  of  blood  pre- 
viously drawn  from  their  renal  veins,  or  by  transfusion  from  normal  animals. 

Failure  of  renal  activity  is  denoted  by  the  symptoms  commonly  spoken  of 
as  uraemia,  a  condition  probably  caused  in  part  by  the  failure  of  the  kidneys 
to  rernove  certain  substances  from  the  blood,  and  partly  by  failure  of  these 
organs  to  contribute  their  internal  secretion.  The  condition  may  be  brought 
about  either  through  renal  disease,  or  as  a  result  of  surgical  or  other  trauma 
inflicted  upon  the  kidneys. 

In  the  event  of  the  destruction- of  a  portion  of  the  secreting  structure  of  the 
kidney,  to  a  limited  extent  a  compensatory  action  of  the  remaining  kidney  tissue 
is  noted,  the  compensation  being  in  part  an  increased  function  of  the  normal 
cells,  and  in  part  as  hyperplasia,  particularly  of  the  cortex,  so  that  after  .uni- 
lateral nephrectomy,  or  destruction  of  one  kidney  by  disease,  the  remaining 
organ  may  become  nearly  double  its  former  size.  As  would  be  expected,  com- 
pensatory hypertrophy  is  most  marked  in  young,  healthy  individuals. 

ANOMALIES  OF  THE  KIDNEY 

The  kidneys  may  vary  from  normal  in  number,  size,  shape,  position,  at- 
tachment, and  mobility. 

Morris,  in  an  analysis  of  11,168  autopsies,  found  an  abnormality  of  the 
kidney  once  in  every  two  hundred  and  eleven  subjects.  Exclusive  of  movable 
kidney,  sixteen  cases  of  multiple  ureter,  and  fifty-three  cases  of  acquired  atrophy, 
the  usual  anomaly  was  fused  or  horseshoe  kidney. 

There  may  be  more  than  two  kidneys  (Fig.  310),  or  there  may  be  congenital 
absence  of  one  kidney  (Fig.  311).  This  latter  has  been  noticed  sufficiently 
often  to  warrant  the  suggestion  that  the  surgeon,  before  performing  nephrec- 
tomy, should  make  sure  of  the  presence  of  two  kidneys. 

Roberts  collected  twenty-nine  cases  of  solitary  kidney,  twenty-two  of  which 
occurred  in  males  and  six  in  females.  The  sex  was  not  given  in  one  case.  In 
sixteen  cases  the  left  kidney  was  absent,  in  thirteen  the  right. 

Ballowitz  found  that  the  deficiency  was  more  common  on  the  left  than  on 
the  right  side,  and  that  the  single  kidney  was  usually  normal  in  position  and 
shape,  but  enlarged.  A  single  kidney  has  sometimes  a  double  vascular  supply 
and  two  ureters,  though  showing  no  other  signs  of  fusion.  Morris  states  that 
congenital  absence  of  one  kidney  can  be  expected  once  in  every  two  thousand 
four  hundred  and  fifty-four  and  one-fifth  cases. 

The  kidney  may  be  congenitally  enlarged;  this  condition  is  usually  asso- 
ciated with  atrophy,  or  possibly  with  absence,  of  the  other  kidney,  and  is  com- 
pensatory. A  single  large  kidney  seems  to  be  perfectly  competent  to  carry  on  the 
functions  of  both  organs,  since  there  are  many  autopsies  recorded  showing  that 
the  bearers  of  this  malformation  have  lived  to  an  advanced  age  and  perished 
of  other  diseases.  Thus,  Newman  reports  seventeen  such  cases,  the  patients 
dying  at  ages  greater  than  sixty. 

Variations  in  shape  may  be  due  to  overgrowth  or  malformation  of  neigh- 
boring organs  or  structures.  Usually  these  are  true  growth-perversions,  and 
they  may  assume  a  great  variety  of  forms. 

The  upper  or  lower  extremities  of  the  kidney  may  be  joined  by  a  bridge 
over  the  abdominal  aorta  and  inferior  vena  cava,  the  organ  assuming  horse- 


SURGERY  OF  THE  KIDNEYS 


591 


shoe  shape  (Fig.  312);  this  connection  may  consist  of  true  kidney  structure 
or  may  be  merely  a  band  of  connective  tissue.  It  may  closely  simulate  tumor 
of  the  stomach.  The  kidneys  may  be  fused  along  their  whole  inner  surface, 
forming  one  large  oval  or  rounded  organ,  with  blood-vessels  and  excretory  ducts 
attached  to  its  centre  or  possibly  to  one  side.  It  is  stated  that  there  is  one 
horseshoe  kidney  in  every  seven  hundred  and  seven  examinations.  Fusion  may 
present  certain  bizarre  forms,  as  in  a  case  reported  by  Gruber,  in  which  one 
kidney  was  superimposed  upon  the  other,  the  long  axes  of  the  organs  lying  at 
right  angles  to  each  other,  and  both  being  displaced  from  their  normal  position. 


Fig.  311. — Single  kidney  and  ureter. 
The  kidney  is  abnormally  large.  The  blad- 
der shows  the  entrance  of  but  one  ureter. 
Both  vasa  deferentia  and  seminal  vesicles 
are  present.  (From  the  Mutter  Museum, 
College  of  Physicians,  Philadelphia.) 


Fig.  312. —  Horseshoe  kidney.  A  large  calculus 
lies  imbedded  in  the  right  side.  (No.  70-4-3. 
Museum  of  Pathology,  University  of  Pennsylvania.) 


The  kidney  may  be  found  extremely  lobulated,  a  condition  norm.al  in  the  foetus. 
When  it  persists  it  is  due  to  arrested  development.  Double  ureter  and  multiple 
arteries  and  veins  are  often  noted.  Fused  kidneys  sometimes  reach  enormous  size. 
The  position  of  the  kidney  may  vary  from  the  normal  in  practically  any 
direction  except  posteriorly.  The  kidney  may  lie  too  high,  but  this  is  extremely 
rare.  It  is  often  found  over  the  sacro-iliac  articulation,  and  has  been  so  widely 
displaced  that  it  has  been  found  in  the  canal  of  Nuck.  Both  kidneys  may  lie 
to  one  side  of  the  vertebral  column,  either  about  their  normal  position  or  in  the 
pelvis.    The  kidney  may  be  tilted,  rotated,  or  turned  on  its  long  axis.     The 


592  GENITO-URINARY  SURGERY 

hilum  may  look  forward,  outward,  downward,  upward,  or  backward;  this  mal- 
position may  be  associated  with  fusion. 

The  anomalies  of  mobility  are  of  sufficient  surgical  importance  to  receive 
special  consideration  (see  "  Movable  Kidney  ").  The  other  growth-perversions 
usually  excite  no  symptoms,  and  are  of  importance  to  the  surgeon  principally 
because  they  may  cause  errors  in  diagnosis  and  treatment.  Thus,  a  malformed 
abnormally  placed  kidney  first  discovered  during  the  course  of  abdominal 
palpation  for  the  detection  of  the  cause  of  obscure  gastro-intestinal  troubles 
might  readily  lead  to  serious  error;  the  removal  of  a  diseased  kidney  would 
necessarily  be  fatal  should  this  happen  to  be  an  instance  of  solitary  kidney, 
partial  nephrectomy  of  the  diseased  portion  of  a  fused  kidney  has  been  success- 
fully performed  several  times.  When  the  kidney  is  fixed  in  a  faulty  position  it 
usually  gives  rise  to  no  symptoms.  Morgagni,  however,  states  that  aortic 
aneurism  was  caused  by  the  pressure  of  horseshoe  kidney,  and  Neufville  records 
the  case  of  a  woman,  twenty-five  years  old,  previously  free  from  symptoms, 
who  in  consequence  of  the  sudden  congestion  of  a  horseshoe  kidney  developed 
thrombosis  of  the  large  veins,  which  was  followed  by  death. 

The  only  operation  practicable  for  the  relief  of  symptoms  due  to  a  kidney 
congenitally  fixed  in  a  faulty  position  is  nephrectomy. 

NEPHROPTOSIS 

Nephroptosis,  or  unduly  mobile  kidney,  is  exceptionally  due  to  a  congenital 
anomaly  in  the  attachment  of  the  organ,  which  is  completely  enveloped  in  a 
fold  of  peritoneum,  and  is  loosely  attached  to  the  posterior  wall  of  the  abdomen 
by  a  mesonephron;  hence  it  lies  within  the  peritoneal  cavity.  Nor  can  a 
recognition  of  this  rare  condition,  termed  floating  kidney,  be  made  by  means 
other  than  operative.  The  term  movable  kidney  is  applied  when  the  peritoneal 
relations  are  normal  but  an  excessive  mobility  is  present. 

Movable  kidney  is  seven  times  as  frequent  in  women  as  in  men.  The 
causes  of  unnatural  mobility  are  such  as  lessen  the  intra-abdominal  pressure,  or 
mechanically  press  or  pull  the  kidney  from  its  normal  recess.  Intra-abdominal 
pressure  is  lessened  suddenly  by  parturition,  more  gradually  by  emaciation  and 
weakening  of  the  abdominal  muscles.  The  kidney  is  thrust  or  dragged  from  the 
paravertebral  space  by  strain  or  traumatism,  lateral  curvature  of  the  spine,  the 
action  of  gravity,  particularly  in  cases  of  pathological  enlargement,  as  in  hydro- 
nephrosis and  calculus,  constriction  of  the  lower  ribs,  as  in  the  case  of  tight 
lacing,  and  the  weight  of  overlying  or  attached  organs,  such  as  the  liver  or  the 
hollow  viscera.  In  about  twenty  per  cent,  of  cases  both  kidneys  are  abnormally 
movable.  The  left  kidney  alone  is  rarely  affected.  The  greater  frequency  with 
which  the  right  kidney  is  involved  (eighty  per  cent.)  is  explained  by  its  relation 
to  the  liver  and  the  greater  length  of  its  artery. 

Three  degrees  of  mobility  have  been  described:  first  degree,  when  the  fingers 
of  the  palpating  hand  can  feel  the  kidney;  second  degree,  when  the  fingers  can 
be  brought  together  above  the  organ;  third  degree,  when  the  kidney  can  be 
depressed  into  the  iliac  fossa. 

Pathology. — A  wide  range  of  motion  vadcy  cause  neither  symptoms  nor 
pathological  change.  It  is  only  when  because  of  such  notion  there  is  interference 
with  circulation,  the  veins  being  particularly  involved,  or  blocking  of  drainage 


SURGERY  OF  THE  KIDNEYS  593 

due  to  ureteral  kink  or  tvvist,  or  injurious  pull  on  neighboring  organs,  that  the 
condition  becomes  in  itself  a  surgical  one. 

The  vessels  and  fascia  are  elongated  and  thinned,  the  ureter  often  partially 
twisted  or  kinked,  and  the  renal  pelvis  shows  dilatation  from  recurring  attacks 
of  hydronephrosis.  The  kidney  may  be  slightly  enlarged  from  passive  conges- 
tion, or  may  present  distinct  evidence  of  degeneration  from  back  pressure. 
Perirenal  and  periureteral  adhesions  may  form  from  the  same  cause.  The 
peritoneum  over  the  kidney  is  lax,  the  duodenum  may  be  elongated,  and  the 
gall-bladder  may  show  the  signs  of  biliary  retention  secondary  to  traction  on 
the  common  duct.  In  long-continued  cases  there  may  be  found  the  phenomena 
of  chronic  gastro-intestinal  catarrh  often  associated  with  general  splanchnoptosis. 

Symptcms. — Aside  from  the  detection  of  the  tumor  by  palpation,  the  cardi- 
nal symptom  is  pain,  usually  referred  to  the  lumbar  region.  This  may  amount 
to  simply  a  dragging  and  wearing  sensation,  made  worse  by  exertion  and  relieved 
by  rest;  or  it  may  be  paroxysmal,  agonizing  in  type,  exactly  resembling  the 
attacks  of  renal  colic  caused  by  blocking  of  the  ureter  and  sudden  tension.  These 
paroxysms  recur  at  irregular  periods,  are  rather  sudden  in  onset,  and  often  follow 
fatigue  or  active  exertion.  Frequently  associated  with  this  pain  are  distinct 
gastro-intestinal  symptoms.  If  the  right  kidney  is  unduly  movable,  it  may 
partially  block  the  bile-duct  and  the  duodenum,  either  by  direct  pressure  or  by 
dragging,  thus  causing  hepatic  colic,  dilatation  of  the  stomach,  and  symptom.s 
of  gastric  catarrh.  When  the  left  kidney  is  movable,  the  same  partial  blocking 
or  dragging  may  affect  the  stomach  or  the  transverse  and  the  descending  colon, 
thus  interfering  with  intestinal  digestion. 

The  renal  colic  may  be  referred  to  the  lower  part  of  the  abdomen  and 
radiate  into  the  groin  and  down  the  thigh.  Shortly  there  develop  great  tender- 
ness over  the  kidney  both  in  front  and  behind,  and  abdominal  distention  and 
tenderness  to  such  an  extent  as  to  make  renal  palpation  difficult.  This  condition 
may  persist  for  days,  but  usually  subsides  in  a  few  hours. 

The  urine  is  usually  scanty  and  contains  blood.  Hypersecretion  is  an  early 
sign  of  relief  of  tension.  WTien  fever  develops,  the  diagnosis  may  be  exceedingly 
difficult. 

Neurasthenia  is  commonly  associated  with  nephroptosis,  as  are  flatulence, 
constipation,  and  other  signs  of  gastro-intestinal  catarrh,  sometimes  reflex  in 
origin,  usually  due  to  general  visceroptosis.  By  pressure  against  the  vena  cava 
and  particularly  against  the  ovarian  vein  there  may  be  kept  up  a  passive  con- 
gestion of  the  pelvic  organs,  causing  menstrual  disturbances  and  predisposing 
to  chronic  inflammation  (Goelet). 

Morris  calls  attention  to  the  fact  that  movable  kidney  and  large  gall-bladder 
are  each  more  frequently  met  with  in  women  than  in  men,  and  often  occur 
in  the  same  person.  The  association  of  the  two  states  is  explained  by  the 
custom  of  wearing  corsets.  While  the  downward  pressure  of  the  liver  induces 
mobility  of  the  kidney,  the  mobility  of  the  kidney  in  turn  acts  upon  the  gall- 
bladder and  causes  distention  by  dragging  upon  the  duodenum  and  the  bile- 
ducts,  thus  obstructing  the  passage  of  the  bile.  The  same  mechanism  explains 
the  frequency  with  which  gastric  dilatation  and  symptoms  of  gastro-intestinal 
catarrah  are  associated  with  movable  kidney. 

If  the  mobility  is  sufficiently  great  to  cause  kinking  of  the  ureter,  hy- 


594  GENITO-URINARY-  SURGERY 

dronephrosis  will  result.  In  this  event  the  symptoms  will  be  those  of  that  con- 
dition (see  p.  663). 

Diagnosis. — This  is  based  on  the  history  of  a  sufficient  cause  for  undue 
mobility,  and  of  continuous  or  paroxysmal  pain,  often  with  profuse  urinatioa 
following  the  paroxysms,  on  associated  symptoms  of  gastro-intestinal  derange- 
ment, on  the  finding  of  a  movable  tumor  by  abdominal  palpation  and  by  radio- 
grams. If  a  tumor  lying  in  the  hypochondriac,  the  umbilical,  or  even  the  iliac 
region  exhibits  the  characteristic  depression  of  the  hilum,  if  the  pulsation  of  the 
renal  artery  can  be  recognized,  if  the  growth  on  manipulation  readily  recedes 
into  the  loin,  and  if  it  is  of  the  size  and  consistence  of  the  kidney,  the  diagnosis 
becomes  reasonably  certain. 

Palpation  of  the  kidney  may  be  performed  with  the  patient  in  a  sitting 
posture,  the  back  being  thoroughly  supported,  or  in  the  dorsal  decubitus.  In 
the  latter  position  the  thighs  should  be  flexed,  head  and  shoulders  elevated,  and 
the  trunk  slightly  inclined  towards  the  side  to  be  examined  by  a  thin  pillow 
placed  under  the  opposite  loin.  The  examiner  places  the  fingers  of  one  hand 
just  below  the  twelfth  rib,  those  of  the  other  below  the  costal  margin  in  front 
over  the  position  of  the  lower  pole  of  the  kidney,  and  by  gradually  increasing 
bimanual  pressure  sinks  the  anterior  examining  fingers  so  deeply  that  the  kidney 
may  be  felt  in  its  inspiratory  descent.  In  the  majority  of  muscular,  well- 
nourished  patients  with  normally  movable  kidneys  these  organs  cannot  be  felt. 
In  weak  and  emaciated  women  the  kidney,  even  though  but  normally  mobile, 
can  usually  be  felt  on  the  right  side.  When  the  kidney  descends  so  far  during 
inspiration  that  its  expiratory  ascent  can  be  prevented  by  firmly  pressing 
against  it  with  the  examining  fingers,  the  mobility  is  abnormal,  and  this  is  still 
more  true  when  the  entire  organ  can  be  pressed  and  held  downward  by  thrusting 
the  fingers  upward  and  backward  after  a  full  inspiration.  The  gravity  of  renal 
mobility  is,  however,  gauged  by  the  renal  changes  and  the  symptoms  produced 
by  it,  and  these  are  not  necessarily  proportionate  to  the  range  of  motion. 

Malignant  colonic  and  omental  growths,  solid  tumors  of  the  ovaries,  growths 
of  the  abdominal  wall,  and  enlargement  of  the  spleen  can  usually  be  readily 
excluded,  partly  from  the  radical  difference  in  the  history,  symptoms,  and  clini- 
cal course,  mainly  by  careful  palpation,  followed  by  colonic  air-distention  and 
palpation  and  auscultatory  percussion.     The  kidney  lies  behind  the  colon. 

Distention  of  the  gall-bladder  so  closely  simulates  movable  kidney  that 
differentiation  is  extremely  difficult.  Both  may  be  characterized  by  gastro- 
intestinal catarrh,  jaundice,  colicky  attacks,  albuminuria  or  biliuria,  and  the 
presence  of  a  tumor  in  the  right  upper  abdominal  quadrant.  In  distinguishing 
between  these  two  affections  the  history  is  of  cardinal  importance.  Enlarged 
gall-bladder  is  particularly  characterized  by  extreme  ease  of  palpation,  con- 
stant or  increasing  size,  the  slight  influence  of  posture  upon  its  position,  free 
respiratory  movement,  its  apparent  continuousness  with  the  liver  substance 
both  on  palpation  and  percussion,  and  its  limited  range  of  mobility  under 
manual  pressure.  Neither  can  it  be  made  markedly  to  recede  to  the  loin. 
Colicky  attacks  give  no  radiation  downward  and  are  not  attended  or  followed 
by  haematuria.  Movable  kidney  exhibits  limited  respiratory  motion,  but  a 
free  range  incident  to  palpation  or  body  position;  it  can  be  separated  from  the 
liver,  is  at  times  difficult  to  feel,  varies  greatly  in  size,  can  be  made  distinctly 


SURGERY -OF  THE.  KIDNEYS  595 

more  accessible  by  upward  lumbar  pressure,  and  recedes  to  the  loin.  Colicky 
attacks  are  associated  with  pain  radiating  downward,  and  are  attended  and 
followed  by  haematuria. 

Moreover,  the  pressure  upon  a  tender  kidney  produces  a  peculiar  sickening 
much  like  that  incident  to  testicular  trauma.  When  the  surgeon  is  in  doubt,  the 
condition  is  usually  movable  kidney. 

The  two  conditions  may  coexist.  In  this  case  careful  palpation  will  enable 
the  surgeon  to  separate  one  tumor  from  the  other. 

The  distinction  between  movable  kidney  and  calculus  is  readily  made  when 
each  has  developed  typically;  when  the  mobility  of  the  kidney,  though  sufficient 
to  cause  blocking  of  the  ureters,  is  so  slight  that  it  cannot  be  detected  by  pal- 
pation, the  differential  diagnosis  is  made  possible  by  the  skiagraph. 

Omental  or  mesenteric  infiltrations  or  pyloric  carcinoma  cause  neither  the 
colicky  paroxysms  nor  the  urinary  phenomena  of  movable  kidney. 

In  doubtful  cases  conclusive  proof  is  often  furnished  by  radiograms  made 
with  the  patient  in  both  the  erect  and  recumbent  positions,  after  the  injection 
of  collargol,  or  with  radiographic  catheters  in  the  ureters. 

Prognosis. — The  ultimate  prognosis  so  far  as  the  kidney  itself  is  concerned 
is  bad  in  all  cases  accompanied  by  distinct  renal  sypiptoms  and  pathological 
conditions  of  the  urine.  When  the  pain  is  slight,  or,  if  severe  and  paroxysmal, 
when  it  recurs  at  long  intervals,  lasts  but  a  short  time  and  is  relieved  promptly 
by  position  and  rest,  and  when  symptoms  are  not  steadily  increasing  in  severity, 
the  outlook  is  favorable,  and  the  patient  can  probably  be  kept  comfortable  by 
the  wearing  of  a  proper  appliance.  Severe,  long-lasting  pain,  of  frequent  occur- 
rence, necessarily  implies  ultimate  disorganization  of  the  secreting  substance 
of  the  kidney,  since  this  pain  is  due  to  tension  or  twisting  of  the  pedicle,  either 
of  these  conditions  causing  profound  alterations  in  nutrition. 

Pronounced  mobility  may  be  unattended  by  renal  symptoms  or  alterations 
in  the  urine,  and  under  such  circumstaces  does  no  harm.  An  amount  of  motion 
which  cannot  be  detected  by  the  most  careful  palpation  may  be  sufficient  to 
cause  pronounced  symptoms.  Sooner  or  later  a  movable  and  degenerating 
kidney  profoundly  alters  general  nutrition,  often  producing  a  condition  of  melan- 
cholia or  neurasthenia.  The  gastro-intestinal  symptoms  when  once  well  de- 
veloped are  commonly  progressive  unless  the  mechanical  cause  is  removed. 

Debove  has  shown  that  chronic  hydronephrosis  of  one  side  may  cause  in- 
terstitial nephritis  of  the  other. 

Treatment. — This  is  either  palliative  or  radical. 

Palliative  Treatment. — The  condition  can  be  palliated,  often  cured,  by  a  rest 
cure  of  five  weeks  in  the  dorsal  decubitus,  with  particular  attention  paid  to 
abdominal  massage,  correction  of  slight  lateral  spinal  curvature,  exercises  calcu- 
lated to  develop  the  abdominal  muscles,  and  the  application  of  a  support,  so 
planned  that  the  abdominal  parietes  are  evenly  supported  and  enteroptosis  is 
prevented.  The  straight-front  corsets  are  well  adapted  to  this  purpose.  The 
corset  must  be  accurately  fitted  by  measurements  taken  with  the  patient  in 
dorsal  decubitus  with  elevated  hips,  and  should  always  be  laced  on  with  the 
patient  in  this  position  (Fig.  313).  Its  greatest  pressure  should  be  exerted 
upon  the  lower  abdominal  segment,  the  front  being  carried  down  as  far  as 
possible.    Moderate  support  should  be  afforded  at  the  waist-line,  and  great  care 


596 


GENITO-URINARY  SURGERY 


should  be  taken  to  see  that  there  is  no  pressure  above  this  line.  In  place  of 
the  corset  a  pad  held  in  place  by  a  spring  truss  serves  well  (Fig.  314).  The 
pad  fills  the  space  above  the  pubis  and  within  the  flare  of  the  pelvis  to  the  level 
of  the  anterior  superior  spines  of  the  ilium,  and  by  its  spring  presses  the 
abdominal  content  upward  and  backward.    In  some  cases  of  nephroptosis  and 


Fig.  313. — Proper  method  of  applying  corset  for  movable  kidney.    (Dr.  Ernest  A.  Gallant.) 


Fig.   314. — Lane-Curtis  abdominal  support 

general  visceroptosis  a  dressing  of  adhesive  plaster  is  more  efficient  than  the 
corset  or  truss  (Fig.  315). 

Patients  must  be  cautioned  against  violent  exertion  or  straining  of  any 
kind.  The  bowels  must  be  "kept  soluble,  since  the  muscular  effort  required  to 
evacuate  hardened  faeces  tends  to  displace  the  kidney.  Digestive  disturbances 
should  be  corrected  by  diet  and  proper  medication,  and  due  attention  should 
be  given  to  general  hygiene.    The  acquisition  of  abundance  of  fat  is  much  to 


SURGERY  OF  THE  KIDNEYS 


597 


be  desired.     When  in  spite  of  this  treatment  the  symptoms  of  obstruction  per- 
sist, nephrorrhaphy  is  indicated. 

When  sudden  violent  pain  shows  that  the  pelvis  or  ureter  is  blocked,  an 
attempt  should  at  once  be  made  to  place  the  kidney  in  its  proper  position.     In 


24-  3Z'. 


]i 


-36'— ^0' 


Fig.  315. — Rugh's  plaster  belt  for  nephroptosis.  Diagram 
at  top  shows  variable  dimensions  in  inches  of  the  two  strips  of  zinc  oxide 
plaster  used  in  the  dressing.  A  and  B,  anterior  and  posterior  views 
respectively  after  applications  of  first  belt;  C  and  D,  anterior  and  pos- 
terior appearance  after  the  application  of  the  second  belt. 

the  intervals  of  paroxysmal  pain  this  is  usually  accomplished  without  difficulty. 
Patients  suffering  from  movable  kidney  are  apt  to  be  thin,  with  lax  abdominal 
walls:  hence  the  kidney  can  be  distinctly  palpated,  and  pressure  can  be  so 
exerted  that  it  will  slip  readily  into  its  norm.al  place. 

During  the  attacks  of  pain,  especially  when  these  are  complicated  by  symp- 
toms of  local  peritonitis,  this  reposition  may  be  difficult.   Nevertheless,  it  should 


598 


GENITO-URINARY  SURGERY 


always  be  attempted,  ether  being  given  if  necessary.  No  force  should  be  used, 
since  the  surgeon  is  to  a  certain  extent  acting  blindly.  The  kidney  should  be 
outHned,  mobilized,  and  restored  to  its  normal  position  if  possible.  Severe  pain 
is  quieted  by  a  hot  bath  and  the  use  of  hypodermics  of  morphine,  repeated  as 
often  as  may  be  necessary.  Hot  compresses  should  be  applied  over  the  ab- 
dominal surface  when  tympany  develops. 

Operative  Treatmejtt. — This  has  for  its  end  fastening  the  kidney  in  its 
normal  position  by  sutures  and  adhesions,  the  operation  being  known  as  nephror- 
rhaphy  or  nephropexy.  It  is  indicated  when  in  association  with  an  abnormal 
degree  of  mobility  the  symptoms  are  distinctly  renal,  and  do  not  yield  to  rest, 
hygiene,  and  a  proper  abdominal  support. 


Fig.  316. — Edebohls's  position;  air  pillow  beneath  abdomen — chest  raised  from  table 
by  pads  beneath  shoulders.  Incision  (AB)  from  costovertebral  angle  (at  the  junction  of  the 
sacrospinalis  muscle  with  the  last  rib)  forward  just  below  the  rib;  it  may  be  extended  to  the 
rectus  muscle  if  needful  (the  patient  then  being  turned  on  the  side).  Vertical  incision  (AC)  to 
the  outer  side  of  the  sacrospinalis  muscle  and  parallel  with  it — used  when  the  operative  procedure 
is  simple  and  a  long  waist  gives  ample  room.     D,  iliac  crest. 


Wlien  both  kidneys  are  to  be  operated  upon  the  patient  is  placed  in  the 
ventral  decubitus  across  an  air-cushion  (Fig.  316).  When  but  one  kidney  is 
to  be  secured,  it  is  more  convenient  to  have  the  patient  lying  on  the  sound 
side  (Fig.  317),  that  thigh  and  leg  being  flexed,  while  the  thigh  and  leg  of 
the  affected  side  extend  nearly  straight  downward.  The  arm  of  the  sound  side 
should  be  drawn  forward  of  the  chest  to  prevent  pressure  on  the  nerves,  and 
the  upper  shoulder  should  drop  slightly  forward.  An  air-cushion  or  some  similar 
device  should  be  placed  in  the  iliocostal  space. 

The  instruments  required  are  a  strong  scalpel  of  medium  size,  dissecting 
forceps,  toothed  forceps,  half  a  dozen  haemostatic  forceps,  two  broad  right-angled 
retractors,  two  large  curved  needles,  and  a  grooved  director.  The  usual  in- 
cision for  nephropexy  in  long-waisted  individuals  starts  at  the  costovertebral 
angle  at  the  juncture  of  the  twelfth  rib  and  the  outer  edge  of  the  sacrospinalis 


SURGERY  OF  THE  KIDNEYS 


599 


(erector  spinse)  muscle,  and  passes  downward  along  the  outer  margin  of  this 
muscular  mass  to  the  crest  of  the  ilium.  The  strong  dorsolumbar  fascia  (Fig. 
318)  is  cut  close  to  the  side  of  the  sacrospinaHs,  giving  access  to  the  kidney 
space  without  dividing  muscular  tissue.  The  retractors  are  passed  down  to 
the  perinephric  fat,  and  the  wound  is  spread  open  as  widely  as  possible.  While 
an  assistant  presses  the  kidney  upward  and  backward  into  its  normal  position, 
the  fatty  capsule  is  seized  in  rat-tooth  forceps  and  opened  with  a  knife,  after 
which  the  dorsal  surface  of  the  kidney  is  freely  exposed.  The  sutures  of 
chromicized  No.  2  catgut  are  inserted  in  the  postero-convex  border,  one  near 
the  upper  pole,  the  other  well  below  the  middle,  thus  preventing  inward  or 
forward  rotation.  Each  is  passed  from  above  downward  for  half  an  inch  beneath 
the  capsule,  then  from  below  upward  the  needle  entering  a  quarter  of  an 
inch  from  its  previous  point  of  exit  for  half  an  inch,  coming  out  near  the 


s. 
\ 


t 


Fig.  317. — Lateroventral  lithotomy  position  (ventral  rotation  a  little  more  marked 
than  indicated  in  the  picture).  A,  Costovertebral  angle,  about  four  fingers'  breadth  from  the  line 
of  the  vertebral  spines.  Line  of  incision  parallel  with  the  last  rib  and  half  a  finger's  breadth  below 
it,  running  forward  to  the  rectus  or  even  beyond  its  outer  border,  as  required.  Border  of  last  rib 
and  crest  of  the  ilium  indicated. 

point  of  original  entrance  (Fig.  319).  Brodel  has  demonstrated  that  thus  placed 
the  sutures  stand  three  times  as  much  traction  as  by  the  older  methods,  and 
are  hence  much  less  Hkely  to  tear  out  from  the  effort  of  coughing  or  vomiting. 
These  sutures  are  carried  through  the  fatty  capsule,  transversalis  fascia,  and 
deep  muscles,  and  are  tied  down  after  the  incision  through  the  muscles  and 
fascia  is  firmly  closed  by  a  sufficient  number  of  buried  catgut  sutures.  Xo 
drainage  is  used. 

After  operation  the  patient  should  lie  in  the 'dorsal  decubitus  for  at  least 
five  weeks,  should  wear  a  supporting  bandage  or  straight-front  corset  for  six 
months,  and  should  avoid  violent  strain  or  muscular  effort  for  a  much  longer 
period.  The  mortality  of  the  various  forms  of  nephrorrhaphy  is  less  than  two 
per  cent.  Mechanical  cure  is  the  rule,  and  in  the  majority  of  properly  selected 
cases  complete  relief  from  symptoms  may  be  expected. 


600 


GENITO-URINARY  SURGERY 


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SURGERY  OF  THE  KIDNEYS 


601 


Many  surgeons  prefer  to  incise  the  capsule  of  the  kidney  a  little  back  of 
the  midline,  strip  it  up  for  a  short  distance  to  each  side,  and  insert  two  or 
three  mattress  sutures  into  each  leaf  of  the  capsule,  the  ends  of  the  sutures 
being  brought  out  through  the  muscles  on  each  side  of  the  incision,  and  tied 
down  after  the  muscle  wound  has  been  closed. 

When  the  operation  of  nephrorrhaphy  has  been  carefully  performed  twice 
and  has  been  unsuccessful,  or  when  it  is  impossible  to  place  the  kidney  in  the 
proper  position,  and  symptoms  are  severe  and  progressive,  nephrectomy  is  a 
justifiable  operation. 

Newman  gives  the  mortality  of  this  operation  for  movable  kidney  as  thirty 
per  cent.  The  operation  is  not  to  be  considered  unless  there  is  absolute  certainty 
as  to  the  existence  of  a  sound  kidney  which  is  able  to  carry  on  the  work  of 
elimination.    For  the  purpose  of  total  removal  the  kidney  may  be  reached  from 


Fig.  319. — Sustaining  sutuies  for  fixing  the  kidney.     (Brodel.) 

in  front  through  the  linea  alba  or  the  linea  semilunaris,  or  from  the  lumbar 
region,  as  in  the  operation  of  nephrorrhaphy.  When  ureteral  catheterization 
has  failed  to  demonstrate  the  condition  of  the  other  kidney,  or  even  its  presence, 
the  abdominal  operation  is  to  be  preferred. 

The  treatment  just  given  for  movable  kidney  is  applicable  to  floating  kidney; 
in  operating,  however,  the  peritoneal  cavity  must  be  opened  unless  the  two 
layers  of  the  mesonephron  are  widely  separated. 


INJURIES  OF  THE   KIDNEYS 

In  accordance  with  surgical  classification,  injuries  of  the  kidney  may  be 
considered  under  the  general  headings  contusions  and  wounds,  the  former  ex- 
hibiting no  external  wound  leading  down  to  this  organ. 

Contusion  of  the  Kidney. — Direct  violence  is  instanced  by  kicks,  blows, 
or  crushing  pressure,  as  from  the  wheels  of  a  cart,  applied  to  the  lumbar  region. 
Except  in  cases  complicated  by  fractured  bones  and  injury  to  other  important 


502  GENITO-URINARY  SURGERY 

viscera,  the  vulnerating  body  is  usually  small,  or  at  least  narrow,  since  there  is 
a  comparatively  small  unprotected  space  through  which  it  can  act  directly  on  the 
kidney,  particularly  when  it  is  applied  suddenly  and  unexpected,  thus  surprising 
the  parietes  when  they  are  relaxed,  and  when  the  ilio-costal  space  is  broadest. 
Direct  violence  usually  involves  the  right  kidneys  of  men. 

Indirect  violence  is  instanced  by  contortions  or  flexions  of  the  trunk,  or 
by  violent  jarring  from  a  fall. 

The  injury  may  yary  in  severity  from  moderate  contusion  to  laceration,  or 
to  complete  disintegration. 

The  first  degree  of  contusion  (Tuffier)  is  characterized  by  subcapsular  ecchy- 
moses.  When  the  violence  has  been  more  marked  (second  degree),  intrarenal 
blood  extravasations  are  found,  most  marked  and  constant  at  the  base  of  the 
pyramids.  In  the  third  degree  the  capsule  is  ruptured ;  there  is  extrarenal 
hemorrhage,  and  deep,  multiple,  stellate  fissures  of  the  kidney-substance  are 
produced,  most  pronounced  about  the  hilum,  sometimes  completely  dividing  the 
kidney.  Finally,  the  organ  may  be  reduced  to  a  pulpy  detritus;  exceptionally  a 
large  branch  of  the  renal  artery  may  be  ruptured.  Bleeding  within  the  kidney 
is  rarely  profuse.    Extrarenal  hemorrhage  may,  however,  be  fatal. 

Severe  contusion  of  the  kidney  is  often  complicated  by  rupture  of  the  liver, 
the  spleen,  the  intestines,  the  lungs;  the  peritoneum  lying  in  front  of  the  kidne}^ 
is  likely  to  be  torn,  particularly  in  children,  in  whom  the  fatty  envelope  of  the 
kidney  is  wanting.  Injuries  to  the  kidneys  are  the  most  frequent  visceral  lesions 
of  abdominal  contusions;   as  a  rule,  other  viscera  are  not  involved,  (Mackin). 

Symptoms. — Symptoms  of  contusion  of  the  kidney  are  shock,  pain,  haema- 
turia,  diminution  in  the  quantity  of  urine  passed,  and  the  formation  of  a  tumor. 

Shock  is  usually  pronounced,  particularly  when  the  kidney  is  lacerated  or 
completely  ruptured.  However,  it  may  be  slight  even  in  case  of  rupture,  and 
may  be  entirely  wanting  in  slight  contusion  characterized  by  superficial  or 
parenchymatous  ecchymoses. 

Pain,  usually  the  first  symptom,  varies  in  intensity  from  a  sickening,  weak- 
ening ache  to  an  unbearable  anguish  comparable  to  that  characteristic  of 
nephritic  colic.  It  is  felt  in  the  lumbar  region,  but  usually  radiates  down  the 
ureters,  and  is  often  accompanied  by  retraction  of  the  testis.  It  may  be  transi- 
tory, or  may  last  for  several  days.  It  is  often  accompanied  by  nausea,  vomiting, 
and  tympany.  When  it  persists  it  is  liable  to  be  paroxysmal,  and  is  then 
probably  due  to  temporary  ureteral  obstruction  and  kidney  tension,  caused  by 
the  passage  of  clots  through  the  ureter. 

Hsematuria  may  follow  an  injury  to  the  abdominal  wall,  and  does  not 
necessarily  indicate  that  the  substance  of  the  kidney  has  been  bruised.  When 
it  is  easily  excited  it  is  usually  a  sign  of  a  masked  lesion  of  the  kidney,  such 
as  encysted  calculus,  which  may  have  been  dislodged,  or  a  preexisting  thrombus, 
or  tumor,  or  renal  tuberculosis. 

When  the  kidney  is  contused  hsematuria  is  practically  constant,  and  is  often 
profuse.  Blood  may  appear,  either  immediately  after  the  injury  or  not  for 
several  hours;  it  may  persist  for  several  days,  or  may  be  abundant  for  a  day 
or  two  and  then  suddenly  cease,  because  the  .ureter  is  blocked  by  a  clot.  In  this 
case  there  will  probably  be  renal  colic;  when  the  clot  is  passed  pain  will  cease, 
and  there  will  be  recurrence  of  blood  in  the  urine.    The  quantity  of  blood  passed 


SURGERY  OF  THE  KIDNEYS  603 

is,  as  a  rule,  proportionate  to  the  severity  of  the  lesion.  If,  however,  the  ureter 
is  torn  across,  or  if  it  becomes  at  once  blocked  by  a  large  clot,  the  urine  may 
remain  perfectly  clear,  even  though  the  kidney  be  pulpified. 

The  blood  usually  disappears  within  a  week.  Sometimes  it  persists  for 
several  weeks,  and  exceptionally,  instead  of  growing  less,  it  steadily  augments 
in  quantity  until  the  patient  perishes  of  anaemia.  The  clot,  in  place  of  passing 
through  the  ureter,  may  permanently  occlude  it,  causing  hydronephrosis  or 
atrophy  of  the  kidney.  Butler  reports  a  case  of  left  ureteral  obstruction  from 
clots  incident  to  renal  trauma  persisting  for  fourteen  days,  with  complete  sup- 
pression of  urine.  The  nontraumatized  kidney  was  found  at  autopsy  to  be 
atrophic  and  cystic.  Frequent  and  painful  urination  is  not  an  uncommon 
symptom  when  blood  is  passing  through  the  ureter  in  the  shape  of  clots  which 
act  as  foreign  bodies  in  the  bladder ;  often  there  is  retention  of  urine. 


F,iG.  320. — Perirenal  extravasation  of  the  blood. 

Alteration  in  the  quantity  of  urine  secreted  constitutes  an  important  symp- 
tom of  kidney  contusion.  Urine  may  be  totally  suppressed  immediately  after 
the  injury,  or  this  suppression  may  not  develop  until  some  hours  later.  It  is 
often  followed  by  compensatory  polyuria. 

The  formation  of  a  tumor  is  primarily  due  to  hemorrhage;  even  though  this 
be  subcapsular  the  enlargement  may  be  palpable.  When  the  capsule  is  rup- 
tured and  there  is  free  bleeding  into  the  perinephric  tissues,  there  is  quickly 
(hours)  formed  an  extensive  and  increasing  area  of  dulness  and  swelling  in  the 
lumbar  and  possibly  in  the  iliac  region.  The  hemorrhage  may  be  so  rapid  and 
profuse  that  marked  constitutional  symptoms  '  develop — i.e.,  feebleness  and 
rapidity  of  the  pulse,  pallor,  coldness  of  the  extremities,  and  collapse.  Tumor 
of  the  loin  was  present  in  one  hundred  and  eleven  of  Watson's  four  hundred 
and  eighty-six  cases.  It  was  usually  due  to  perinephric  abscess,  hydronephrosis, 
or  pyonephrosis;  thirty-nine  cases  were  caused  by  perirenal  bleeding  and  four 
by  hsematonephrosis. 


504  GEXITO-URIXARY  SURGERY 

Rayer  states  that  in  intrarenal  bleeding  the  swelling  is  sharply  circum- 
scribed,  forms  later  and  more  slowly  than  in  perirenal  extravasation,  ana  is 
rounded  and  movable.  Perirenal  extravasation  is  diffuse  (Fig.  320).  Satis- 
facton,-  palpation  is  in  these  cases  often  impossible,  because  of  the  exquisite 
sensitiveness  of  the  kidne\'  and  the  region  about  it.  When  the  hemorrhage  is 
confined  to  the  pelvis  of  the  kidney  and  the  ureter  it  seldom  forms  an  appreciable 
tumor. 

A  perirenal  blood  effusion  is  sometimes  evacuated  with  the  urine,  this  occur- 
ring, according  to  Tufner  and  Levi,  towards  the  end  of  the  second  week  follow- 
ing the  injury  and  being  characterized  by  the  subsidence  of  the  tumor  and  the 
reappearance  of  blood  in  the  urine,  which  may  have  been  clear  for  several  days. 

Rupture  may  take  place  into  the  peritoneal  cavity,  a  complication  which 
is  generally  fatal.  Intraperitoneal  bleeding  is  characterized  by  the  rapid  de- 
velopment of  tympanites  and  signs  of  peritonitis,  together  with  symptoms  of 
internal  hemorrhage. 

Diagnosis. — The  diagnosis  of  contusion  of  the  kidney  is  based  on — (1) 
The  form  of  traumatism:  thus,  the  sharp  corner  of  a  table  striking  the  side 
between  the  pehis  and  the  costal  border,  a  kick  or  a  blow  delivered  from  before 
backward  below  the  ribs  and  over  the  region  of  the  kidneys,  a  crushing  force 
fracturing  the  lower  ribs,  or  extreme  flexion  or  extension  of  the  body,  would  be 
sufficient  cause  for  kidney-rupture.  (2)  The  appearance  of  blood  in  the  urine, 
in  the  absence  of  bladder-lesion.  The  rare  cases  in  which  such  bleeding  follows 
simple  traumatism  of  the  back  may  be  disregarded.  If  the  bleeding  is  profuse 
and  exhibits  worm-like  clots,  it  offers  the  characteristics  of  traumatic  renal 
hemorrhage;  the  renal  origin  of  the  hemorrhage  may  also  be  recognized  by 
cystoscopy.  (3)  Marked  diminution  in  the  quantity  of  urine  secreted,  or  com- 
plete suppression  of  the  secretion.  This  symptom  may  follow  any  severe  trauma- 
tism to  the  abdominal  contents.  It  may  be  of  value  when  associated  with  hemor- 
rhage. (4)  The  rapid  formation  of  a  lumbar  swelling  associated  with  extreme 
tenderness.  (5)  Intense  pain  radiating  in  the  direction  of  the  ureter  and 
accompanied  by  retraction  of  the  testis.  (6)  Subcutaneous  ecchymoses  de- 
veloping several  days  after  the  injury.  These  may  appear  in  the  loin,  or  may 
be  foimd  in  the  inguinal  region.  Dumesnil  has  particularly  insisted  upon  the 
importance  of  this  symptom,  and  states  that  it  is  indicative  of  serious  injury. 

The  group  of  S3'mptom5  is  diagnostic.  It  has  been  shown,  however,  that 
they  are  often  not  associated;  thus,  haematuria,  the  most  characteristic  symp- 
tom, ma\''  be  absent;  but  if  the  kidney-lesion  is  extensive  a  haematcma  is  cer- 
tain to  form,  ^^'hen  the  peritoneum  is  ruptured,  and  extensive  bleeding  takes 
place  into  the  general  peritoneal  ca\-ity.  the  onty  symptoms  pointing  to  injury  of 
the  kidney  will  be  haematuria  and  possibly  characteristic  pain;  shock  and 
peritonitis  quickly  mask  the  other  symptoms  indicative  of  kidney-lesion.  Ab- 
dominal symptoms  are  occasionally  noted,  however,  in  the  absence  of  intra- 
peritoneal rupture:  they  occurred  in  eighteen  of  Watson's  cases.  They  become 
marked  immediately  or  ver}'  soon  after  the  accident,  are  of  relatively  short 
duration,  and  are  not  progressively  severe.  The  one  sure  sign  of  intraperitoneal 
rupture  of  the  kidney  is  free  fluid  in  the  peritoneal  cavity,  as  indicated  bv  non- 
circumscribed,  generally  bilateral,  movable  dulness.  In  cases  uncomplicated 
by  peritoneal  rupture  the  area  of  dulness  is  unilateral,  and  is  more  or  less  cir- 


SURGERY  OF  THE  KIDNEYS  605 

cumscribed,  extending  three  or  four  fingers'  breadth  below  the  costal  arch  and 
as  far  forward  as  the  mid-clavicular  line,  bpon  us  progressive  rapid  increase  in 
size  often  depends  the  advisabihty  of  operative  interference.  Progressive,  but 
slow,  increase  in  size  of  this  area  of  dulness  occurs  with  the  development  of 
perinephric  abscess  (sixteen  of  Watson's  cases),  and  with  hydronephrosis  (eight 
of  Watson's  cases). 

Ruptured  bladder  is  characterized  by  pain  in  the  hypogastrium  with  vesical 
tenesmus  and  the  passage  of  a  small  amount  of  bloody  urine,  or  inability  to 
pass  any  urine  and  the  finding  of  an  empty  bladder  (see  p.  481). 

Prognosis. — Most  cases  of  contusions  of  the  kidney  of  the  first  degree, 
characterized  by  subcapsular  ecchymosis,  heal  spontaneously  apparently  without 
sequelae,  and  probably  this  is  true  of  the  cases  exhibiting  disseminated  extrava- 
sations into  the  substance  of  the  kidney.  When  the  organ  is  extensively  ruptured 
the  prognosis  is  grave.  According  to  Morris,  the  two  chief  conditions  upon 
which  recovery  depends  are  the  escape  of  the  peritoneum  and  of  the  large 
branches  of  the  renal  artery  and  vein;  if  a  large  branch  of  the  renal  artery  be 
torn,  and  death  does  not  follow  from  bleeding,  the  gradually  increasing  hemor- 
rhage is  likely  to  lead  by  pressure  to  sloughing  of  the  peritoneum,  even  though 
that  membrane  may  have  escaped  the  original  injury.  Recovery  may  follow 
extensive  laceration  or  even  complete  pulpification  of  the  kidney.  This,  how- 
ever, is  rare.  Duplay  and  Reclus  state  that  in  simple  lacerations  the  mortality 
is  forty-three  per  cent.;  in  laceration  complicated  by  rupture  of  other  organs 
or  fractures  of  the  neighboring  bones  the  mortality  is  eighty-seven  per  cent. 

Complications. — Complications  which  are  immediately  threatening  to  life 
after  rupture  of  the  kidney  are  shock,  hemorrhage,  and  anuria.  Later  the  chief 
danger  is  from  sepsis;  the  conditions  are  so  favorable  for  its  development  that 
it  is  one  of  the  most  frequent  causes  of  death  in  patients  who  survive  the 
immediate  effects  of  the  injury.  If  the  kidney  capsule  has  been  ruptured  sup- 
puration extends  into  the  perinephric  tissues.  Chills,  fever,  increasing  pain 
and  tenderness  in  the  lumbar  region,  and  marked  diminution  in  the  quantity 
of  urine  secreted,  should  suggest  the  probability  of  infection  and  should  lead 
to  lumbar  incision. 

Cystitis  is  a  complication  which  often  follows  uncleanly  catheterization  and 
may  even  lead  to  infection  of  the  sound  kidney.  Hydronephrosis  may  develop 
as  a  consequence  of  the  blocking  of  the  ureter  by  a  clot;  this,  in  case  of  infection, 
becomes  converted  into  pyonephrosis.  Traumatic  peritonitis  from  the  escape 
of  blood  and  urine  into  the  peritoneal  cavity,  and  thrombosis  of  the  renal 
vessels,  are  sequelae  that  have  been  frequently  fatal.  The  kidney  may  be  dis- 
placed from  its  normal  position,  and  thereafter  may  remain  preternaturally 
movable.  As  a  remote  sequel  of  traumatism  various  forms  of  Bright's  disease 
may  develop.  Exceptionally  the  blood-clots  form  nuclei  for  renal  stones. 
Ebstein  holds  that  contusion  is  a  predisposing  factor  in  the  development  of 
renal  tumors. 

Treatment . — Shock  is  treated  in  accordance  with  general  surgical  principles. 
When  there  is  reason  to  believe  that  the  kidney  is  bruised,  the  patient  is  put  to 
bed,  is  kept  absolutely  quiet,  and  is  given  hypodermic  injections  of  morphine 
for  the  relief  of  pain  if  this  is  severe.  When  the  hemorrhage  is  profuse,  blood- 
serum  is  given  hypodermically,  an  ice-bag  is  applied  to  the  lumbar  region,  and 


506  GENITO-URINARY  SURGERY 

the  side  is  strapped  with  long  strips  of  adhesive  plaster,  applied  as  for  fractured 
ribs.  In  addition  to  the  straps  a  broad  roller  bandage  is  applied;  this  secures 
a  compress  of  gauze  or  cotton  over  the  kidney.  It  is  unwise  to  give  either 
medicine  or  food  by  the  mouth  for  the  first  few  hours,  since  the  patient  is  likely 
to  vomit,  and  this  may  cause  recurrence  of  bleeding.  The  straining  and  retching 
which  occur  even  when  the  stomach  is  empty  are  best  relieved  by  sufficient 
doses  of  morphine.  Thirst  may  be  appeased  by  rectal  injections  of  half-normal 
salt  solution,  a  pint  at  a  time,  at  blood  heat. 

A  fairly  well-nourished  man  can  subsist  for  many  days  without  nourishment 
of  any  kind,  and  it  is  wise  to  withhold  even  liquid  food  until  the  stomach  is 
retentive.  For  three  weeks  at  least  after  suspected  injuries  of  the  kidney  the 
diet  should  be  moderate  in  quantity  and  simple  in  quality,  and  the  intestinal 
evacuations  should  be  so  regulated  as  to  be  accomplished  without  straining. 
Coughing,  sneezing,  forced  efforts  at  micturition,  or  defecation,  sitting  up,  any 
act  which  may  suddenly  change  the  conditions  of  intra-abdominal  pressure, 
should  be  avoided.  As  soon  as  the  stomach  becomes  retentive,  salol  or  hexa- 
methylenamine  should  be  given  by  the  mouth  for  the  purpose  of  rendering  the 
urine  slightly  antiseptic,  and  the  patient  should  drink  an  alkaline  water  freely, 
since  the  lower  the  specific  gravity  of  the  urine  the  less  the  tendency  towards 
the  formation  of  clots. 

Should  retention  of  urine  develop  because  of  clots  blocking  the  urethra,  an 
effort  should  be  made  to  reUeve  this  condition  by  a  hot  bath.  This  failing,  the 
suction  catheter  or  the  litholapaxy  tube  and  evacuator  may  be  used.  These 
instruments  must  be  employed  with  minute  attention  to  aseptic  precautions. 
Should  the  suction  catheter  or  the  evacuating-tube  not  succeed  in  evacuating 
the  bladder-contents,  or  should  there  be  frequent  recurrence  of  retention  from 
clots,  requiring  repeated  catheterizations,  cystotomy  is  indicated,  followed  by 
the  insertion  of  a  large  tube,  and  by  frequent  irrigations  of  the  bladder. 

Should  haematuria  persist  and  constitutional  symptoms  show  that  loss  of 
blood  is  producing  dangerous  anaemia,  surgical  intervention  is  imperative.  This 
should  take  the  form  of  an  exploratory  lumbar  incision.  The  kidney  can  thus 
be  thoroughly  exposed,  the  extent  of  injury  determined,  and  the  bleeding 
stopped  by  ligature  of  the  torn  vessel,  ligation  and  excision  of  a  portion  of  the 
kidney,  firm  packing,  or  nephrectomy.  This  last  operation  is  indicated  when 
the  kidney  exhibits  multiple  and  extensive  lacerations.  Lumbar  incision  is  also 
indicated  in  cases  exhibiting  no  blood  in  the  urine,  but  rapidly  developing  a 
lumbar  tumor  associated  with  symptoms  of  internal  bleeding,  and  in  those 
showing  the  constitutional  and  local  symptoms  of  infection. 

Owing  to  the  depth  and  inaccessibility  of  the  wounded  vessels,  it  may  be 
impossible  to  tie  them,  or,  even  if  they  were  tied,  the  blood-supply  of  the 
kidney  might  be  thereby  so  curtailed  that  necrosis  would  be  certain  to  result. 
Under  these  circumstances  nephrectomy  is  indicated.  Children  are  less  able 
than  adults  to  resist  internal  hemorrhage,  but  are  apparently  more  likely  to 
recover  from  nephrectomy.  Therefore  nephrectomy  in  them  may  be  performed 
with  less  absolute  indications  than  with  adults.  When  a  lesion  of  the  peritoneum 
is  suspected,  a  transperitoneal  operation  should  be  performed. 

Of  two  hundred  and  seventy-three  cases  treated  expectantly,  twenty-seven 
per  cent,   died;    of   one'  hundred   and   fifteen    cases   treated   by  nephrectomy, 


SURGERY  OF  THE  KIDNEYS  607 

twenty-five  per  cent,  died;  of  ninety-eight  cases  treated  by  operation  other 
than  nephrectomy,  seven  per  cent.  died.  Hemorrhage  and  sepsis  caused  the 
greatest  number  of  deaths  (Watson). 

Wounds  of  the  Kidney. — Wounds  of  the  kidney,  much  rarer  than  con- 
tusion or  rupture,  are  conveniently  classed  in  accordance  with  their  causes  as 
gunshot,  punctured,  and  incised  wounds. 

Gunshot  Wounds. — A  bullet  which  wounds  the  kidney  is  very  likely  to 
injure  other  viscera.  Of  seventy-eight  cases  of  gunshot  wound  of  the  kidney 
reported  by  Otis,  other  viscera  were  wounded  in  thirty-three.  Balls  usually 
pass  through  the  kidney,  sometimes  leaving  in  its  substance  portipns  of  clothing; 
exceptionally  they  are  buried  in  the  secreting  portion  of  the  organ:  thus,  Simon 
found  a  bullet  encysted  in  the  kidney  parenchyma. 

The  bullet  may  wound  simply  the  secreting  substance  of  the  kidney,  may 
pass  through  the  pelvis,  or  may  tear  the  great  vessels.  When  the  wound  in- 
volves only  the  kidney-substance  there  is  moderate  bleeding  with  no  extrava- 
sation of  urine,  and,  provided  other  organs  are  spared,  healing  takes  place  with 
extraordinary  rapidity.  The  modern  army  rifle,  either  at  close  or  at  long  range, 
may  practically  pulpify  the  entire  organ. 

When  the  pelvis  is  opened  there  will  be  urinary  extravasation.  This,  how- 
ever, need  not  lead  to  infection.  The  bleeding  is  usually  more  profuse  than 
when  only  the  secreting  substance  of  the  kidney  is  involved,  and,  unless  the 
ureter  'is  torn  completely  across,  there  will  be  hsematuria.  When  the  large 
vessels  are  cut,  hemorrhage  is  so  severe  as  to  threaten  life.  The  blood  may 
be  poured  out  into  the  perinephric  tissues,  into  the  peritoneal  cavity,  and 
into  the  bladder  through  the  ureter. 

Punctured  v^^ounds,  such  as  those  made  with  a  needle  in  kidney  explora- 
tion, are  entirely  safe,  unless  infection  is  carried  with  the  vulnerating  instrument. 
When  made  with  a  comparatively  blunt  instrument,  as  the  prong  of  a  hay- 
fork, there  are  contusion  and  laceration  in  addition  to  the  puncture,  and  the 
consequences  are  the  same  as  those  incident  to  gunshot  wound. 

Incised  wounds  are  rare,  since  the  position  of  the  kidney  protects  it. 
Incised  wounds  are  much  more  liable  to  be  entirely  extraperitoneal  than  are 
those  inflicted  by  fire-arms.  The  wound  of  entrance  is  often  in  the  lumbar 
region;  stabs  and  cuts  inflicted  from  in  front  rarely  extend  backward  as  far 
as  the  kidney.  As  in  the  case  of  gunshot  wounds,  these  injuries  may  involve 
the  secreting  substance,  may  open  the  pelvis,  may  divide  the  large  vessels,  or 
may  sever  the  ureter. 

A  few  cases  have  been  reported  in  which,  after  extensive  wound  of  the 
lumbar  region,  the  kidney  has  protruded. 

Symptoms. — The  chief  symptom  of  wound  of  the  kidney  is  haematuria.  If 
the  pelvis  has  been  opened  there  will  also  be  escape  of  urine  through  the 
wound.  Pain  may  be  severe,  assuming  the  type  of  kidney  colic.  Oliguria  is 
constant;   exceptionally  there  is  complete  suppression  of  urine. 

Diagnosis. — The  diagnosis  is  based  on — 1,  the  nature  of  the  vulnerating 
body,  its  direction,  and  the  depth  to  which  it  has  penetrated;  2,  blood  in  the 
urine;  3,  escape  of  urine  from  the  wound;  4,  examination  of  the  kidney  through 
the  wound  or  through  a  lumbar  or  an  abdominal  incision. 

When  the  entrance-wound  of  a  bullet  is  over  the  kidney,  and  the  direction 


508  GENITO-URINARY  SURGERY 

of  its  track  is  towards  this  organ,  this  constitutes  a  reasonable  ground  for  sus- 
pecting injury  to  the  kidney,  since  the  course  of  a  bullet  in  the  body  is  usually 
straight;  haematuria  would  then  make  the  diagnosis  reasonably  certain.  The 
kidney  may,  however,  be  injured  by  a  ball  which  enters  the  body  at  a  con- 
siderable distance  from  the  parietes  overlying  it;  thus,  Otis  mentions  a  case  in 
which  the  bullet  entered  just  below  the  clavicle.  Haematuria  and  escape  of 
urine  through  the  wound  are  diagnostic  of  wound  of  the  pelvis  or  of  the  ureter 
rather  than  of  the  kidney. 

Palpation  of  the  kidney  is  sometimes  possible  through  an  incised  wound, 
such  as  would  be  infiicted  by  a  stab  with  a  broad-bladed  dirk. 

Prognosis. — Incised  wounds  of  the  kidney  heal  readily;  even  though  the 
pelvis  is  opened  and  there  is  escape  of  urine,  this  does  not  materially  interfere 
with  recovery,  provided  the  ureteral  lumen  is  not  encroached  on.  These  injuries 
are  dangerous  chiefly  from  primary  hemorrhage,  which  is  likely  to  be  profuse, 
and  from  the  wounding  of  other  viscera.  Of  thirty-one  incised  wounds  collected 
by  Duplay  and  Reclus,  eight  died.  In  six  of  these  the  kidney-wound  was  com- 
plicated by  involvement  of  other  viscera. 

In  the  absence  of  profound  shock  and  severe  hemorrhage,  the  prognosis  of 
kidney-wound  is  favorable,  even  though  the  organ  is  very  extensively  injured, 
since  in  the  great  majority  of  cases  the  wound  is  unilateral  and  occurs  in  per- 
sons possessed  of  a  sound  kidney  capable  of  performing  the  work  of  both.  The 
prognosis  of  wounds,  opening  the  peritoneum  overlying  the  kidney,  is  much 
more  serious  than  is  that  of  extraperitoneal  wounds.   . 

Gunshot  wounds  commonly  involve  other  viscera.  Thus,  of  thirty-eight 
cases  collected  by  Duplay  and  Reclus,  eleven  of  the  sixteen  deaths  were  at- 
tributable to  multiplicity  of  the  lesions.  The  complications  and  sequelae  of 
wounds  of  the  kidney  are  those  described  when  considering  contusions;  the 
danger  of  infection  is  greater  in  wounds  than  in  contusions,  since  it  may  reach 
the  kidney  either  from  the  ureter  or  from  the  parietal  opening. 

Treatment . — The  general  treatment  of  wound  of  the  kidney  is  that  already 
described  as  appropriate  to  contusion.  The  wound  itself  should  be  cleansed, 
and  should  be  drained,  even  though  there  be  no  escape  of  urine,  since  the 
vulnerating  body  is  never  sterile. 

When  a  bullet  entering  the  body  from  in  front  has  passed  towards  the 
kidney,  and  there  follow  haematuria  and  symptoms  of  internal  hemorrhage, 
coeliotomy  should  be  performed  at  once,  since  this  enables  the  operator  not 
only  to  deal  with  the  kidney,  but  to  recognize  and  close  wounds  of  the 
abdominal  viscera.  When  the  wound  is  in  the  lumbar  region  and  there  is  doubt 
as  to  whether  or  not  the  peritoneal  cavity  has  been  entered,  the  lumbar  incision 
is  preferable. 

The  indication  for  immediate  operation,  as  far  as  the  kidney  is  concerned, 
is  hemorrhage.  The  kidney  having  been  exposed,  either  by  an  incision  through 
the  linea  alba,  along  the  outer  border  of  the  rectus  muscle,  or  in  the  lumbar 
region,  according  to  the  position  of  the  v/ound,  the  bleeding  point  is  sought  for 
and  secured,  by  ligature  or  suture,  if  this  is  possible,  or  by  packing  in  case 
the  ligature  cannot  be  applied  and  there  seems  a  fair  prospect  of  saving  the 
kidney,  or  by  nephrectomy. 

If  the  wound  involves  only  the  secreting  portion  of  the  kidney,  it  should 


SURGERY  OF  THE  KIDNEYS 


609 


be  cleaned,  and  packed.  If  the  renal  artery  or  vein  is  torn,  or  if  the  kidney  is 
,so  extensively  disorganized  that  repair  is  impossible,  nephrectomy  is  indicated. 
If  the  pelvis  is  opened,  it  should  be  closed  by  suture,  if  possible,  or  provision 
made  for  lumbar  drainage.  If  the  ureter  is  torn  across  its  upper  portion,  lumbar 
drainage  is  usually  indicated,  since  from  loss  of  blood  the  patient  is  not  pre- 
pared to  stand  a  prolonged  plastic  operation.  Should  recovery  take  place,  im- 
plantation of  the  ureter  into  the  pelvis  may  be  effected  subsequently.  Blood  or 
extravasated  urine  found  in  the  peritoneal  cavity  should  of  course  be  removed 
by  gentle  sponging,  the  kidney  being  then  shut  off  from  this  cavity  by  suture  of 
the  peritoneum.  Extensive  accumulation  of  blood  in  the  perinephric  and  post- 
peritoneal  tissues  should  be  removed,  since  absorption  is  slow  and  huge  abscesses 
will  develop  if  infection  occurs. 

NEPHRECTO^IY 

The  operation  usually  referred  to  by  the  term  nephrectomy  is  the  extracap- 
sular removal  of  the  kidney  through  a  loin  incision.  Other  methods  of  removing 
the    kidney    are    the    subcapsular    lumbar  , 

operation,  lumbar  morcellement,  and  trans- 
peritoneal nephrectomy.  Subtotal  nephrec- 
tomy is  rarely  performed. 

Lumbar  Extracapsular  Nephrec- 
tomy.— The  incision  should  be  four  inches 
long,  beginning  about  two  and  a  half  inches 
from  the  spines  of  the  vertebrae,  and  run- 
ning parallel  to  the  twelfth  rib,  and  a  full 
half  inch  below  it,  in  order  to  avoid  wound- 
ing the  pleura.  This  incision  may  be  pro- 
longed when  needful  almost  to  the  midline 
of  the  abdomen  (see  Fig.  321),  the  sheath 
of  the  rectus  being  opened  and  that  muscle 
displaced.  The  fibres  of  the  external  and 
internal  oblique  muscles  must  be  divided; 
the  transversalis  may  be  split  in  the  direc- 
tion of  its  fibres.  By  careful  suture  of  the 
fascia  of  the  individual  layers  a  strong 
abdominal  wall  may  be  left.  When  the 
upper  pole  is  closely  adherent  mobilization 
of  the  twelfth,  or  twelfth  and  eleventh  ribs 
(see  Figs.  322,  323,  and  324)  is  sometimes 
needful.  When  the  kidney  has  been  ex- 
posed, as  in  nephrorrhaphy,  and  freed  from  any  adhesion  to  its  fatty  capsule, 
and  blood-clots  have  been  removed,  it  should  be  delivered  by  passing  the  fore- 
finger about  one  of  the  poles  (the  upper  is  usually  the  one  first  delivered),  and 
drawing  it  outward  and  backward  till  it  rests  on  the  parietal  wound  surface;  the 
lower  pole  is  turned  out  in  a  similar  manner.  Its  pedicle  should  be  dissected  free 
of  its  fibro-fatty  investment  till  the  blood-vessels  and  ureter  can  be  separately 
clamped.  The  former  are  seized  in  two  pairs  of  forceps  not  less  than  a  quarter 
of  an  inch  from  each  other,  are  sectioned  distal  to  the  peripheral  forceps,  and 
39 


Fig.  321. — Lateral  view,  showing 
extent  of  transverse  incision  when  free  ex- 
posure is  needful.  A,  Costovertebral  angle; 
B,   end  of  12th  rib. 


610 


GENITO-URINARY  SURGERY 


SURGERY  OF  THE  KIDNEYS 


611 


^3 


612 


GENITO-URINARY  SURGERY 


SURGERY  OF  THE  KIDNEYS 


613 


/ 


Renal  vein 
Renal  artery 


325. — Nephrectomy.      The   pedicle  has  been  doubly  clamped. 
It  is  usually  possible  to   avoid  inclusion  of  the   ureter. 


ire  tied  between  the  two  instruments  by  a  transfixing  chromic-gut  ligature. 
The  proximal  forceps  is  then  removed,  and  a  circumferentiating  ligature  is 
knotted  tightly  in  its  groove.  The  ureter  is  crushed,  tied,  and  cauterized  (Figs. 
325,  326,  and  327).  The 
wound  should  be  irrigated 
with  sterilized  water  or 
sublimate  solution  and 
packed  with  sterile  gauze,  ( 
or  it  may  be  partially  closed 
and  drained  with  a  rubber 
tube,  which  should  be  re- 
moved in  three  or  four 
days. 

Transperitoneal  Ne- 
phrectomy.— N  e  phrec- 
tomy  through  an  incision 
in  the  linea  semilunaris, 
known  as  Langenbuch's  fig 
operation,  is  indicated  when 
the  wound  has  probably  involved  other  organs  and  has  opened  the  peritoneal 
cavity;  this  approach  is  also  serviceable  in  the  removal  of  tumors  of  large  size, 
and  in  children.  This  incision  should  be  at  least  four  inches  long.  When  the 
abdominal  cavity  has  been  opened,  the  opposite  kidney  is  palpated,  not  only  to 
make  sure  of  its  existence,  but,  furthermore,  to  ascertain,  as  far  as  possible,  its 

condition  of  health  and 
whether  or  not  it  can  en- 
dure the  strain  of  double 
duty.  If  it  be  absent  or 
diseased,  the  operation 
must  be  abandoned.  If 
this  examination  of  the  un- 
injured kidney  shows  that 
it  is  probably  healthy,  the 
intestines  are  pushed  aside 
from  the  affected  kidney, 
the  outer  layer  of  the  meso- 
colon is  exposed,  and  a 
vertical  slit  is  cut  in  it  over 
the  kidney  (Fig.  328),  the 
general  cavity  being  pro- 
tected by  careful  gauze 
packing. 
If  the  peritoneum  has  been  wounded,  blood  and  extravasated  urine  are 
sponged  out  and  intraperitoneal  injuries  are  treated  before  dealing  with  the 
kidney,  unless  there  is  bleeding;  in  that  case  no  time  is  lost  in  fully  exposing 
the  organ.  The  kidney  is  enucleated  from  its  fatty  capsule  as  in  the  lumbar 
operation,  and  the  vessels  and  ureter  are  tied  off  and  divided.     It  is  advisable 


F;g.  326. — Nephrectomy.  Pedicle  ligated  and  kidney  re- 
moved. When  the  first  ligature  is  passed  between  the  clamps, 
a  second  may  be  placed  in  the  groove  of  the  proximal  forceps.  A' . 
Ilioinguinal  nerve;  the  iliohypogastric,  usually  also  exposed  in  the 
incision,  lies  posterior  and  is  not  visible. 


614 


GENITO-URINARY  SURGERY 


in  this  operation  to  provide  drainage  through  a  lumbar  wound  for  three  or 
four  days.  The  peritoneum  overlying  the  kidney  should  be  completely  closed 
by  suture,  and  the  abdomen  closed  without  drainage.    Unless  there  are  lesions 


ext.  oblique 
int.  oblique 


cut  edge  of) 
lumbar  fascia  >  h^iji^^i. 
twelfth  rib).  I 

serratus  post.  inf. 

lat.  dorsi 

quadratus  lumb. 


Fig.  32  7. — Nephrectomy.     Vein  and  artery  held  apart  for  separate  ligation. 

r"  •,, 


Ascending  colon 


Fig.     328. — Incision  of  the  parietal  peritoneum  to  outer  border  of  colon  in  transperitoneal  nephrectomy. 

of  the  abdominal  viscera,  or  unless  from  the  nature  of  the  wound  it  is  probable 
that  infection  "will  follow.  When  abdominal  nephrectomy  is  performed  after 
infection  has  developed,  the  peritoneal  cavity  must  be  freely  drained. 


SURGERY  OF  THE  KIDNEYS 


615 


In  abdominal  nephrectomy  performed  through  an  incision  in  the  linea  alba 
the  inner  layer  of  the  mesocolon  is  incised  in  order  to  reach  the  postperitoneal 
kidney-space.  Thereafter  the  procedure  is  the  same  as  in  Langenbuch's  opera- 
tion. Profuse  hemorrhage  from  cutting  one  of  the  large  veins  running  along 
the  inner  layer  of  the  mesocolon  frequently  happens;  this  may  be  prevented  by 
cutting  in  the  line  of  the  veins,  or  by  tying  beforehand  those  vessels  which 
inevitably  must  be  cut.  Drainage  should  be  secured  through  a  counter-opening 
in  the  lumbar  region. 

The  main  advantage  of  the  abdominal  route  is  the  opportunity  it  affords 
of  examining  into  the  condition  of  the  uninjured  kidney  and  of  detecting  and 
repairing  associated  injuries  of  the  intraperitoneal  viscera. 

Subcapsular  Nephrectomy. — When  the  fibrous  capsule  of  the  kidney  is 
firmly  adherent  to  the  fatty  capsule  it  may  be  impossible  to  separate  the  two, 
and  be  necessary  to  remove  the  kidney  by 
stripping  it  from  within  its  enveloping 
membrane.  In  doing  this  the  capsule 
should  be  incised  along  the  convexity 
of  the  kidney  and  stripped  down  each 
side  as  far  as  the  hilum.  A  choice  of 
procedure  then  lies  between  clamping  the 
pedicle  within  the  capsule,  and,  incising 
the  capsule  about  the  hilum  so  that  it 
slips  back  over  the  pedicle,  ligating  the 
vessels  and  ureter  extracapsiilarly.  When 
it  is  found  quite  impossible  to  ligate  in 
this  manner  it  is  proper  to  apply  the 
ligature  so  as  to  include  the  capsule 
(Fig.  329) ;  but  under  such  circum- 
stances it  is  wise  to  leave  the  clamp  in 
place  with  the  handles  'protruding  from 
the  wound,  removing  it  on  about  the 
second  day,  or  the  clamp  alone  may  be 
relied  upon  for  the  control  of  the  vessels. 

After  loosening  the  clamp  it  is  ad- 
visable to  allow  it  to  remain  in  the  wound 
for  ten  or  twelve  hours  before  withdrawing  it,  thereby  allowing  the  tissues  in 
its  grasp  time  to  become  separated  from  it  and  retract.^  After  securing  the 
pedicle  as  much  of  the  capsule  as  possible  should  be  removed  with  scissors 
and  forceps. 

Nephrectomy  by  Morcellement. — This  little-used  method  is  applicable 
when,  on  account  of  firm  extracapsular  adhesions,  it  is  impossible  to  reach  the 
pedicle  by  the  subcapsular  method  just  described.  The  capsule  is  split  and 
stripped  from  the  kidney  as  in  the  preceding  operation.  Then  a  long,  straight 
clamp  is  applied  to  the  lower  pole  of  the  kidney  just  below  the  hilum,  and  this 
portion  is  cut  away,  making  room  for  the  application  of  a  curved  clamp  to  the 
lower  portion  of  the  pedicle.    The  upper  pole  is  then  similarly  treated,  and  the 

^Mayo:  Surgery,   Gynecology,   and   Obstetrics,   1917,    xxiv,    1. 


Fig.  329. — Subcapsular  nephrectomj-. 


bl6  GENITO-URINARY  SURGERY 

remainder  of  the  pedicle  clamped,  after  which  the  central  portion  of  the  kidney 
is  removed.  If  now  it  is  possible  to  apply  ligatures  to  the  pedicle,  this  is  done 
as  in  the  subcapsular  operation,  otherwise  the  clamps  are  left  in  place  for  four 
days  and  the  wound  closed  about  their  handles. 

Whatever  method  is  used  in  removing  the  kidney,  the  wound  should  be  closed 
with  chromicized  catgut  sutures,  so  that  the  fascial  layers  are  carefully  approxi- 
mated. It  is  generally  best  to  drain  with  tube  or  "  cigarette  "  for  two  or  three 
days. 

Partial  Nephrectomy. — This  operation  is  very  rarely  indicated;  is  more 
dangerous  than  nephrectomy,  when  the  opposite  kidney  is  in  good  condition,  and 
is  less  likely  to  cure  the  condition  for  which  it  is  performed. 

The  kidney  is  delivered,  and  while  an  assistant  compresses  the  pedicle  the 
operator  excises  a  wedge-shaped  piece,  including  the  diseased  area,  and  inserts 
and  ties  the  mattress  chromicized  catgut  sutures  which  shall  bring  the  cut  sur- 
faces together.  These  should  be  placed  ten  to  fifteen  millimetres  apart,  and 
well  back  from  the  margin  of  the  wound.  Drainage  should  be  maintained  for  at 
least  a  week. 

Operative  Complications  and  Accidents. — The  chief  of  these  is  hemor- 
rhage. This  may  arise  from  the  tearing  of  an  anomalous  artery,  most  often 
one  to  the  lower  pole  of  the  kidney,  during  the  freeing  of  the  organ  from  its 
fibro-fatty  or  capsular  investment;  from  one  of  the  vessels  of  the  pedicle,  either 
through  injury  while  applying  the  ligature  or  through  faulty  application  of  the 
ligature;  or  through  injury  to  the  vena  cava,  which,  on  the  right  side,  lies  close 
to  the  kidney,  and  the  wall  of  which  may  be  seized  in  the  clamp  applied  to  the 
pedicle.  Hemorrhage  from  accessory  arteries  is  rarely  alarming,  but  may  be 
difficult  to  control  on  account  of  retraction  of  the  vessel  into  the  fat.  The 
vessel  can  usually  be  secured;  occasionally  packing  is  necessary.  Bleeding  from 
the  vessels  of  the  pedicle  may  be  so  profuse  that  the  patient  becomes  exsangui- 
nated in  a  few  seconds.  If  the  kidney  has  not  yet  been  removed  it  may  be 
possible  to  draw  upon  it  sufficiently  to  efficiently  place  another  clamp.  If 
there  is  no  such  convenient  handle,  the  left  hand  should  be  thrust  into  the  wound 
and  an  effort  made  to  locate  the  pedicle,  grasping  it  between  the  index  and 
middle  fingers ;  a  clamp  may  then  be  passed  down  to  secure  the  vessels.  In  such 
blind  work  there  is,  of  course,  danger  of  catching  one  of  the  abdominal  organs, 
especially  the  duodenum.  Tearing  of  the  vena  cava  has  been  treated  by 
tamponade,  suture,  lateral  ligature,  closure  by  forceps,  and  ligature  of  the  whole 
vein.    The  last-named  method  seems  to  have  given  the  best  results  (Guiteras). 

Opening  the  Peritoneum. — This  has  occurred  many  times,  usually  without  ill 
results,  even  in  infected  cases.  The  presenting  organs  should  be  sponged  off 
with  normal  saline  solution,  and  the  opening  closed. 

Opening  the  pleura,  characterized  by  the  hissing  sound  of  inspired  air,  is 
remedied  by  immediate  suture.  The  slight  resultant  pneumothorax  is  of  little 
moment.  Because  of  the  usual  position  of  the  patient  during  nephrectomy,  such 
an  opening  may  not  cause  even  a  limited  pneumothorax. 

Difficulty  in  Delivering  the  Kidney.— This,  may  be  caused  by  adhesions,  the 
size  of  the  organ,  the  shortness  of  its  pedicle,  or  the  conformation  of  the  indi- 
vidual.    In  thick-muscled,  short- waisted,  deep-chested  individuals  difficulty  in 


SURGERY  OF  THE  KIDNEYS  617 

this  regard  may  be  expected,  and  should  be  avoided  by  dividing  all  the  lower 
attachments  of  the  last  rib  and  drawing  it  upward  and  backward,  or  by  sub- 
periosteally  freeing  and  removing  this  bone  in  the  early  part  of  the  operation 
(Judd)   (Figs.  322,  323,  and  324). 

Duodenal  Fistula. — This  is  a  rare  sequel  of  nephrectomy  on  the  right  side 
(Mayo).  The  descending  portion  of  the  duodenum  overlies  the  pedicle  of  the 
right  kidney.  Injury  is  not  likely  to  occur  except  where  the  pedicle  is  infil- 
trated, so  that  difficulty  is  experienced  in  proper  ligation;  the  clamps  used  to 
control  the  sudden  hemorrhage  from  a  slipping  vessel  may  then  catch  the  duo- 
denum and  so  injure  it  that  a  fistula  results,  usually  four  or  five  days  after 
operation.  The  complication  is  one  of  great  gravity,  three  reported  cases 
having  all  died  of  asthenia.  The  accident  is  to  be  avoided  by  the  use  of  an 
adequate  incision,  by  care  in  securing  the  pedicle,  and,  in  case  of  hemorrhage, 
by  caution  in  the  application  of  clamps;  Mayo  recommends  securing  the  vessels 
with  the  fingers  first,  the  pulsations  of  the  artery  making  them  easily  found. 
Curative  treatment,  as  suggested  by  Mayo,  consists  in  a  transperitoneal  closure 
of  the  fistula,  laying  a  transplant  of  peritoneum  or  omentum  across  the  line 
of  suture,  and  the  formation  of  a  temporary  jejunostomy. 

Anuria  and  urccmia,  from  failure  of  the  remaining,  kidney  to  care  for  the 
needs  of  the  organism,  are  of  comparatively  rare  occurrence  when  due  care  is 
taken  to  ascertain  by  means  of  functional  tests  the  condition  of  this  organ. 
Should  they  supervene,  hot  enteroclysis,  hot  stupes  and  cups  to  the  loin,  general 
hot  packs,  and  the  hypodermic  administration  of  caffeine  sodio-benzoate  and 
of  pituitrin  are  in  order.  Should  these  fail  to  evoke  a  free  flow  of  urine,  exposure 
of  the  remaining  kidney,  with  decapsulation,  pyelotomy,  or  nephrotomy,  should 
be  considered. 

Secondary  hemorrhage  is  of  rare  occurrence,  and  can  usually  be  controlled 
by  packing  with  gauze.  Should  this  fail,  the  bleeding  point  must  be  found  and 
tied. 

Septic  Injection. — This  commonly  occurs  to  a  mild  degree,  but  rarely  to  such 
an  extent  as  to  give  rise  to  anxiety.    Routine  drainage  of  the  wound  is  advisable. 

Sinuses,  here  as  elsewhere,  are  usually  kept  up  by  the  presence  of  some  foreign 
material,  as  a  silk  ligature,  or  a  low-grade  inflammatory  process,  generally  a 
tuberculous  ureter.  The  removal  of  the  former,  and  the  treatment  of  the  latter 
by  tuberculin  and  injections  of  iodoform,  phenol,  and  iodine,  rarely  its  excision^ 
are  the  measures  indicated. 

ANEURISM  OF  THE  RENAL  ARTERY  ■     ' 

This  rare  condition  is  usually  of  traumatic  origin,  twelve  of  the  nineteen 
cases  collected  by  Morris  having  had  tiiis  etiology. 

The  symptoms  are  tumor,  pain,  and  haematuria.  A  bruit  has  sometimes 
been  noted. 

The  treatment  is  nephrectomy,  performed  by  the  abdominal  route  should 
the  diagnosis  have  been  made  prior  to  operation.  Unfortunately  it  is  rarely 
possible  to  make  a  pre-operative  diagnosis. 


CHAPTER  XXVII 
NEPHROLITHIASIS 

The  majority  of  renal  calculi  are  composed  mainly  of  the  oxalate  of  lime. 
This  fact  has  been  demonstrated  by  the  work  of  Rowlands,  of  Mackarell,  Moore 
a,nd  Thomas,  and  of  Kahn  and  Rosenbloom.  Uric  acid  and  phosphate  stones 
occur  with  about  the  same  frequency,  each  about  one-tenth  as  often  as  the 
oxalate.  Uric  acid  stones  are  deposited  in  acid  urine;  the  others  in  urine  with 
an  alkaline  reaction. 

Stones  are  rarely  homogeneous.  Uric  acid  stones  are  more  apt  to  be  pure 
than  are  any  of  the  others.     Neither  size,  color,  shape,  density,  nor  character 

of  surface  can  be  regarded  as  of  any 
value  in  determining  the  composition  of 
a  renal  stone;  a  chemical  analysis  is  the 
only  reliable  method. 

Cystin,  xanthin,  ammonium  urate,  or 
other  urates  are  rare  as  the  principal 
ingredients  of  kidney  stone.  It  is  pos- 
sible that  calculi  may  originate  in  the 
renal  pelvis  about  a  minute  clot.  •  Ex- 
ceptionally concretions  are  found  made 
up  almost  entirely  of  inspissated  blood. 
Foreign  bodies  serving  as  nuclei  are 
extremely  rare.  Frank  has,  however, 
reported  a  case  in  which  an  ordinary 
sewing-needle  formed  the  nucleus  of  stone 
which  caused  an  extensive  perinephric 
abscess.  The  needle  had  been  swallowed 
in  childhood,  and  had  finally  penetrated 
the  pelvis  of  the  kidney  and  there  be- 
come encrusted  with  urinary  salts.  Ros- 
enstein  found  a  calculous  deposit  about  a 
hair,  evidently  from  a  dermoid  cyst  of 
the  kidney. 

The  number  of  calculi  m.ay  vary  from  one  .to  a  thousand.  In  shape  they 
are  seldom  round  or  regular,  owing  both  to  the  shape  of  the  cavity  wherein 
they  are  contained  and  to  their  restricted  attrition  from  motion.  One  large 
calculus  and  numerous  small  ones  may  be  found  filling  up  the  renal  pelvis,  in 
which  case  the  larger  calculus  acting  as  a  ball-valve  may  partially  close  the 
entrance  to  the  ureter  and  only  occasionally  allow  smaller  calculi  to  pass  down. 
Such  may  be  the  case  when  frequent  attacks  of  renal  colic  are  followed  by  the 
618 


Fig.  .330. — Xephrolithiasis.  Branched 
calculi  of  the  pelvis,  exposed  by  cortical  in- 
cision into  the  kidney.  (From  the  Depart- 
ment of  Surgical  Pathologj',  University  of 
Pennsylvania.) 


NEPHROLITHIASIS  •  619 

passage   of   small    calculi   per   urethram,    but   the   general    symptoms   do    not 
ameliorate. 

Kidney  calculi  are  usually  found  in  the  pelvis  or  its  branchings  (Fig.  330). 
Exceptionally  they  are  placed  in  the  substance  of  the  kidney,  as  in  the  case  when 
the  urate  infarcts  of  the  newly-born  form  true  stones.  In  the  absence  of  infec- 
tion calculus  is  generally  adherent,  taking  the  shape  of  the  portion  of  the  pelvis 
in  which  it  is  placed,  often  bifurcating  and  branching  like  a  piece  of  coral,  and 
representing  a  rough  mould  of  the  pelvis  and  its  subdivisions  (Fig.  331).  When 
infection  has  taken  place,  calculi  may  be  found  in  any  portion  of  the  pelvis, 
perhaps  most  frequently  in  its  upper  and  lower  extremities.  Both  kidneys  are 
affected  in  about  fifteen  per  cent,  of  cases. 

Pathological  Changes. — A  calculus  of  moderate  size  may  remain  indefinitely 
in  the  kidney  without  producing  the  slightest  pathological  change  in  the 
secreting  structure.  If  the  calculus  is  so  placed  that  it  suddenly  and  completely 
blocks  the  ureteral  orifice,  the  kidney  will  atrophy.  As  a  usual  sequel  there 
is  gradual  dilatation  of  the  pelvis  and  its  branches,  due  to  partial  obstruction. 
This  may  result  in  either  hydronephrosis  or  atrophy;  occasionally  cystic  de-^ 
generation  occurs  (Fig.  332).  When  infection  has  taken  place — and  this 
occurs,  as  a  rule — there  result  pyelonephritis,  pyonephrosis,  and  often  secondary 
purulent  deposits.  As  a  complication  of  the  kidney  infection  an  indurative  or 
suppurative  perinephritis  may  develop.  Stones  may  ulcerate  into  the  perineph- 
ric tissue. 

Etiology. — The  formation  of  kidney  calculi  is  due  to  the  precipitation  in 
the  kidney  tubules  or  pelvis  of  the  solid  constituents  of  the  urine.  This  precipi- 
tation always  takes  place  on  an  organic  base.  This  may  be  mucus,  epithelial 
cells,  blood-clot,  or  colloid  material.  That  a  coagulation  necrosis  of  cells  caused 
by  interference  with  the  circulation  favors  deposition  of  lime  salts  has  been 
demonstrated  experimentally.  All  concrements,  whether  they  be  the  size  of 
a  grain  of  sand  or  of  a  goose-egg,  have  a  distinct  albuminoid  framework  upon 
which  the  constituents  of  the  urine  are  deposited.  The  difference  between  sand 
and  sediment  lies  in  the  fact  that  in  the  former  the  crystals  are  conglomerated 
about  this  organic  framework. 

Stone-formation  is  commonly  associated  with  the  uric  acid,  the  oxalate,  or 
the  phosphatic  diathesis,  an  excess  of  these  ingredients  favoring  a  coagulation 
necrosis  of  cells,  which  furnishes  the  organic  framework  essential  for  calculus 
formation;  the  same  effect  is  produced  by  local  sepsis. 

Heredity  exerts  a  direct  influence  on  the  development  of  kidney  calculi. 
Leroy  d'fitiolles  records  the  fact  that  of  a  family  of  eight  brothers  who  lived 
in  various  parts  of  Europe  under  different  conditions  of  hygiene  all  had 
calculi. 

Uric  acid  kidney  stones  have  been  found  in  the  foetus.  In  general  renal  cal- 
culi are  most  frequently  observed  in  children  and  after  the  fortieth  year.  The 
uric  infarct  of  the  newly-born,  appearing  as  a  deposition  of  red  and  brown 
crystals,  particularly  of  ammonium  urate,  in  the  epithelium  of  the  pyramidal 


620 


GEXITO-URIXARY  SURGERY 


Fig.  331. — Various  forms  of  kidney-stone,  illustrating  the  irregularities  in  shape.     (Torres.) 


NEPHROLITHIASIS 


621 


"X 


•yf' 


i 


■^. 


tubules,  may  account  for  the  frequency  of  vesical  calculi  in  children;   kidney 
colic  is,  however,  rare  at  an  early  age. 

Renal  calculi  are  commoner  in  men  than  in  women,  the  ratio  being  given  as 
three  to  one.  Duplay  and  Reclus,  however,  hold  that  the  two  sexes  are  equally 
affected. 

Hygienic  surroundings,  climate,  and  diet  seem  to  have  a  definite  relation  to 
the  formation  of  kidney  stone,  but  one  which  has  not  been  clearly  formulated. 

Moist  climates  and  sudden  changes  of 
temperature  apparently  predispose  to 
calculus- formation. 

Men  who  lead  sedentary  lives  and 

j  J^^^    *  '  ^^'  .j^^J     indulge  in  high  living  are  more  liable 

/^^^B'  ^1^1     than    others    to    urinary    concretions. 

y|^|H  ^''^''^4   The  frequency  with  which  renal  calculi 

^  ^^  -^   are  found  among  the  children  of  the 

poorer  classes  has  been  attributed  to 
unfavorable  hygienic  surroundings  and 
coarse  diet. 

Symptoms. — The  chief  symptoms 

of  renal  calculus  are  pain,  haematuria, 

^     ft  '  frequent  urination,   fragments  of  cal- 

tv  S  ^4.    .'^  cuius  appearing  with  the  urine,  pyuria, 

oliguria  or  suppression,  and  symptoms 
of  gastro-intestinal  disturbance.  A 
stone  may,  however,  be  present  in  the 
kidney  for  many  years,  or  through  an 
entire  lifetime,  without  producing 
symptoms. 

The  symptoms  caused  by  kidney 
stone  are  due  to  obstruction  rather 
than  to  the  presence  of  a  foreign 
body;  hence  the  position  of  the 
stone  is  of  more  importance  than  its 
shape  or  size.  Guyon  comments 
on  the  tolerance  of  the  kidneys 
and  ureters  to  foreign  bodies  as 
contrasted  to  their  sensitiveness  to  distention. 

The  pain  of  renal  calculus  is  commonly  referred  to  the  lumbar  region  of 
the  affected  side.  It  is  constant  and  aching  in  character,  and  is  increased  by 
motion,  by  jarring,  and  by  pressure  over  the  kidney.  It  begins  as  a  feeling  of 
weight  or  tension  rather  than  as  an  actual  pain.  It  is  subject  to  sudden  exacer- 
bations, often  occurring  at  night  when  the  patient  is  completely  at  rest.  It 
may  be  referred  to  the  healthy  kidney.  Neuman  reports  two  such  cases,  which 
were  corroborated  by  the  skiagraph  and  by  subsequent  operation.  In  its  exacer- 
bations it  usually  radiates  along  the  course  of  the  ureter  and  into  the  testicle, 
and  may  cause  contraction  of  the  cremaster  muscle,  with  retraction  of  the 
gland.    It  may  be  referred  to  the  thigh  or  the  calf  of  the  leg. 


Fig.  332. — Multiple  bilateral  renal  cysis  and 
calculi.  (Specimen  in  Philadelphia  Hospital 
Museum.) 


622  GENITO-URINARY  SURGERY 

The  reflexes  of  renal  calculus  occasionally  take  the  form  of  intestinal  dis- 
turbances, characterized  by  vomiting  and  violent  intestinal  colic.  Rectal  and 
vesical  tenesmus  are  not  rare.  Urgent  and  painful  urination  is  often  so  marked 
that  attention  is  diverted  from  the  kidney  to  the  bladder. 

Renal  tenderness  elicited  on  deep  palpation  is  a  valuable  symptom.  Murphy 
introduced  what  he  termed  "  fist  percussion  "  as  a  means  of  differentiating 
between  a  renal  lesion  and  one  of  the  gall-bladder  or  appendix.  The  surgeon 
stands  behind  the  patient,  who  should  be  seated  on  the  edge  of  the  bed  or  on  a 
stool,  and,  placing  his  left  hand  firmly  on  the  patient's  back  over  the  sup- 
posedly sound  kidney,  strikes  it  a  strong  blow  with  his  clenched  fist;  the  pro- 
cedure is  then  repeated  on  the  affected  side.  If  a  lesion  which  causes  distention 
of  the  kidney  capsule  be  present  the  patient  cries  out  with  the  pain.  The 
presence  of  nonobstructive  stones  may  render  the  percussion  uncomfortable, 
but  does  not  give  rise  to  the  characteristic  reaction. 

Attacks  of  kidney  colic  when  they  are  recurrent  and  are  induced  by  bodily 
activity  are  particularly  characteristic  of  renal  calculi  (see  p.  574).  Perfectly 
typical  paroxysms  may,  however,  occur  without  the  presence  of  stone.  This 
is  proved  not  only  by  the  large  number  of  cases  reported  in  which,  the  diagnosis 
having  been  based  mainly  on  this  symptom,  the  kidney  was  opened  and  no 
stone  found,  but  also  by  the  cases  in  which,  the  kidney  having  been  exposed 
to  sight  and  touch,  rhythmical  contractions  of  the  ureter  were  observed. 

Hsematuria  is  usually  slight  and  transitory,  and,  except  after  the  attacks 
of  kidney  colic,  can  often  be  detected  only  by  microscopic  examination.  Clots 
are  rare.  The  amount  of  blood  in  the  urine  is  increased  by  jolting,  walking, 
muscular  efforts,  or  renal  palpation;  there  is  sometimes  enough  to  give  the  urine 
a  smoky  appearance.  Sometimes  bright-red  blood  is  passed,  but  this  is  much 
more  characteristic  of  tumor  than  of  calculus;  this  is  true  also  of  clots.  Rest 
in  bed  exerts  a  prompt  and  markedly  beneficial  effect  upon  the  hsematuria. 
There  are  often  found  in  the  urine  blood-cylinders — i.e.,  casts  of  the  uriniferous 
tubules  made  up  of  blood-cells;  these  are  absolutely  characteristic  of  hemorrhage 
of  renal  origin. 

Frequent  urination,  a  pure  reflex  from  renal  and  ureteral  irritation,  is  often 
a  troublesome  symptom  during  the  daytime,  but  is  relieved  when  the  patient 
is  at  rest.  Jacobson  observes  that  nocturnal  and  diurnal  frequency  of  urination, 
when  associated  with  other  symptoms  suggesting  renal  calculus,  indicates  renal 
tuberculosis  with  extension  of  the  process  to  the  bladder-walls,  rather  than  renal 
calculus.  The  frequent  urination  of  kidney  calculus  is  usually  unattended  by 
pain.  When,  together  with  frequency  and  urgency,  there  are  marked  tenesmus 
and  suffering  during  and  after  the  act  of  micturition,  these  symptoms  are 
attributable  to  concomitant  vesical  or  low  ureteral  inflammation. 

The  passage  of  gravel  or  of  fragments  of  calculi  is  a  symptom  commonly 
wanting;  when  present  it  is  of  value  as  indicating  kidney  stone,  even  though 
its  passage  along  the  ureter  does  not  cause  kidney  colic. 

Diminution  or  total  suppression  of  the  urine  lasting  for  a  few  hours  is  a 
fairly  frequent  symptom  of  renal  stone.  When  it  lasts  a  much  longer  time 
(calculus  anuria)  it  should  be  attributed  to  the  simultaneous  obstruction  of 
both  ureters,  or  to  obstruction  of  the  ureter  of  the  only  functioning  kidney. 


NEPHROLITHIASIS  623 

Exceptionally  this  obstruction  may  begin  insidiously,  attracting  no  attention 
until  the  symptoms  of  uraemia  set  in.  Even  for  six  or  eight  days  there  may  be 
no  characteristic  symptoms  other  than  failure  to  pass  water.  After  this  period 
constitutional  symptoms  develop^  in  the  form  of  stupor,  tympany,  diarrhoea,  sub- 
normal temperature,  dry  black  tongue,  often  hiccough  and  ursemic  odor  of  the 
breath. 

Duplay  and  Reclus  particularly  insist  upon  the  importance  of  operating 
promptly  in  cases  of  calculous  anuria,  this  complication  being  an  almost  certain 
proof  of  bilateral  lesion.  After  a  trial  of  prolonged  hot  baths,  warm  rectal 
injections,  abundant  ingestion  of  diluents,  massage  of  the  ureter,  the  use  of  a 
continuous  current  of  electricity,  ureteral  catheterization,  and  profound  anses- 


FiG.  33:i. — Multiple  branched  calculi  of  the  kidney.     (Skiagram  by  Dr.  H.  K.  Pancoast.) 

thetization,  should  anuria  persist  operation  is  indicated.  Forty-eight  hours 
should  be  the  longest  time  allowed  for  these  palliative  measures.  Calculous 
anuria  is  spontaneously  relieved  in  twenty-eight  and  five-tenths  per  cent,  of 
cases.    Sixty-six  and  six-tenths  per  cent,  of  operative  cases  recover  (Legueu). 

The  great  difficulty  in  these  cases  is  to  discover  the  seat  of  obstruction: 
palpation,  the  history  of  the  case,  and  ureteral  catheterization  and  the  X-ray 
may  determine  this.  The  incision  should  be  the  lumbar  one,  and  the  whole  of 
the  ureter  should  be  exposed  if  this  be  necessary. 

Gastro-intestinal  disturbances  are  either  reflex  or  due  to  imperfect  elimina- 
tion on  the  part  of  the  crippled  kidneys.  Tympany,  vomiting,  and  exquisite 
tenderness  at  times  complicate  and  greatly  obscure  attacks  of  renal  colic. 
Chronic  epigastric  tenderness,  feeble  digestion,  and  constant  pain  may  direct  the 
attention  entirely  away  from  the  kidney 


^24  GENITO-URINARY  SURGERY 

Pyuria  is  a  sign  of  pyelitis  or  pyelonephritis;  it  is  classed  as  a  symptom  of 
kidney  calculus  simply  because  it  is  so  frequent  a  complication;  infection 
markedly  aggravates  the  pain,  the  reflexes,  and  the  other  symptoms  already 
described;  it  also  causes  fever  and  favors  the  development  of  pyonephrosis. 

Diagnosis. — The  diagnosis  of  kidney  stone  is  based  on  lumbar  pain  with 
intercurrent  attacks  of  nephritic  colic,  slight  albuminuria  with  hyaline  casts, 


Fig.  334. — Multiple  renal  calculi.     (Skiagram  by  Dr.  H.  K.  Pancoast.) 


hsematuria,  the  passage,  of  gravel  or  of  fragments  of  calculi,  renal  tenderness, 
and  the  use  of  the  X-ray.  These  symptoms  are  rarely  all  present.  Pain  and 
hematuria  are  the  two  most  constant,  and,  with  the  exception  of  the  passage 
of  calculous  fragments,  the  most  characteristic.  The  X-ray  is  the  most  valuable 
means  at  our  disposal  for  determining  the  presence  and  position  of  renal  calculi 
(Figs.  333,  334,  and  335) .    The  only  cases  in  which  the  X-ray  expertly  employed 


NEPHROLITHIASIS 


625 


is  apt  to  fail  to  reveal  a  stone  is  in  the  case  of  calculi  composed  largely  of  uric 
acid.  Care  must  be  exercised  to  exclude  the  presence  of  any  substance  in  the 
intestine  capable  of  thro^Ying  a  shadow  which  might  be  mistaken  for  a  stone. 
For  this  reason  a  purge  should  be  given  the  day  before  the  skiagram  is  made 


Fig.  335. — Calculus  impacted  in  the  pelvic  er. 


kiagram  by  Dr.  H.  K.  Pancoast.) 


(two  compound  cathartic  pills,  crushed,  have  proved  satisfactory),  and  breakfast 
should  be  omitted.  Tenderness  may  be  elicited  either  by  palpation  or  by  direct- 
ing the  patient,  while  in  a  standing  position,  to  strongly  flex  the  thigh  of  the 
affected  side  and  then  suddenly  extend  it,  bringing  the  heel  forciblv  to  the  floor. 
If  a  calculus  be  present,  this  movement,  called  the  stamping  test,  may  cause 


626  GENITO-URINARY  SURGERY 

sudden  acute  renal  pain  (Lucas).  Movable  kidney  often  causes  constant  pain, 
and  acute  exacerbations  precisely  like  those  which  arise  from  stone.  Sometimes 
blood  is  mixed  with  the  urine,  but  only  after  an  acute  attack  of  pain;  the 
movable  kidney  can  sometimes  be  felt  in  its  abnormal  position.  The  comparison 
of  functional  tests  performed  on  the  two  kidneys  is  sometimes  a  deciding  point. 

Commenting  upon  the  difficulty  of  recognizing  the  presence  of  stones  in  the 
kidney  and  ureter,  Cabot  ^  notes  that  the  records  of  153  patients  operated 
upon  for  these  conditions  in  the  Massachusetts  General  Hospital  showed  that 
in  26  cases  abdominal  operations  had  previously  been  performed  without  relief 
of  symptoms.  In  these  cases  the  prominent  symptoms  were  pain  in  right  lower 
abdominal  quadrant  (12  cases),  abdominal  pain  without  colic  (13  cases),  and 
backache  (11  cases).  Urinalysis  was  entirely  negative  in  14  per  cent.;  the 
X-ray  was  negative  in  6  per  cent.  But  pain,  or  urinary  abnormalities,  or  a 
positive  X-ray  were  present  in  every  case. 

Nephralgia  may  simulate  renal  calculus  in  all  respects  except  in  the  presence 
of  blood  or  pus  in  the  urine,  though  Sabatier  states  that  this  affection  also  causes 
haematuria.  Large  quantities  of  limpid  urine  of  low  specific  gravity  are  passed; 
the  suffering  is  aggravated  at  the  catamenia. 

Tuberculosis  of  the  kidney  in  its  early  stages  may  simulate  renal  calculus. 
There  is  haematuria  which  is  apparently  causeless,  and  the  characteristic  reflexes 
develop.  Renal  tuberculosis  is  often  associated  with  hereditary  dyscrasia  and 
with  tuberculous  infiltration  of  the  epididymis,  prostate,  and  vesical  walls. 
Moreover,  repeated  and  patient  examinations  and  inoculations  will  usually  show 
the  tubercle  bacilli  in  the  urine.  Tuberculous  kidney  seems  more  subject  to 
mixed  infection  than  is  the  case  in  calculous  kidney:  hence  there  is  often  a 
great  deal  of  pus  in  the  urine;  this  may  be  thick  and  contain  caseous  particles,, 
which  rapidly  settle  to  the  bottom  of  the  vessel  in  which  the  urine  has  been 
passed. 

Malignant  growths  are  characterized  by  haematuria  much  more  pronounced 
than  that  due  to  calculus,  clots  often  appearing  in  the  urine  in  the  shape  of 
ureteral  moulds;  the  growth  rapidly  and  steadily  increases  in  size. 

Oxaluria  and  strongly  acid  urine  cause  dull  ache,  paroxysmal  pain,  and 
haematuria.  The  pain  is,  however,  not  materially  increased  on  exertion,  the 
tenderness  is  not  distinctly  marked  on  deep  palpation,  and  treatment  is  fol- 
lowed by  prompt  relief. 

Pyelitis  cannot  be  distinguished  from  renal  calculus  with  infection  except 
by  the  history  of  the  case  and  the  X-ray.  Pain  is  not  likely  to  be  so  dis- 
tinctly paroxysmal. 

Spinal  caries  involving  the  lower  dorsal  or  the  lumbar  vertebrae  may  in 
its  symptomatology  closely  simulate  kidney  stone.  Thus,  Wright  reports  a 
case  characterized  by  increased  frequency  of  urination,  intermittent  attacks  of 
pain  causing  nausea  and  vomiting,  testicular  pain,  local  tenderness,  and  oxaluria. 
An  abscess  had  formed  and  by  pressure  on  the  kidney  had  caused  symptoms  of 
calculus. 

The  distinction  between  kidney  stone  and  gall  stone  may  usually  be  made 
by  Murphy's  fist  percussion  (see  p.  622).    The  anterior  position  of  the^pain 

'^  Surg.,  Gynec,  and  Obsfcf.,  1915,  xxi,  403. 


NEPHROLITHIASIS  627 

and  tenderness  with  backward  and  upward  radiations,  the  absence  of  blood  or 
pus  from  the  urine,  the  abundant  secretion  during  the  attack,  and  a  preceding 
history  of  persistent  gastro-intestinal  disturbances  and  attacks  of  jaundice  would 
all  suggest  hepatic  colic. 

Appendicitis  has  frequently  been  confounded  with  renal  calculus  complicated 
by  hydro-  or  pyo-nephrosis,  but  is  characterized  by  the  seat  of  the  tenderness 
and  tumor,  the  persistent  character  of  the  pain  and  gastro-intestinal  disturbances, 
the  unmistakable  rigidity  of  the  right  rectus  muscle,  the  absence  of  blood  and 
pus  from  the  urine,  and  the  pronounced'  pyrexia  and  leucocytosis.  Marked 
flexion  of  the  thigh  is  more  common  in  renal  colic  than  in  appendicitis. 

Locomotor  ataxia  and  hysteria  may  produce  symptoms  closely  simulating 
those  of  renal  calculus.    Examination  of  the  urine  should  exclude  kidney  stone. 

In  thin  persons,  and  when  there  are  many  concrements  (Fig.  334),  on 
palpation  both  tumor  and  crepitus  can  be  detected,  the  latter  particularly  by 
combining  palpation  with  auscultation.     This  is,  however,  exceptional. 

The  most  characteristic  diagnostic  symptoms,  placed  in  their  order  of 
importance,  are  an  unmistakable  skiagram,  passage  of  gravel  or  of  fragments 
of  stone,  attacks  of  typical  renal  colic,  haematuria,  and  ultimately  pyelitis.  It 
is  clear  that  prolonged  study  of  the  urine  is  necessary  before  forming  a  diagnosis, 
the  results  of  this  study  often  sufficing  to  exclude  affections  which  simulate 
renal  calculi. 

It  is  of  extreme  importance  to  determine  whether  one  or  both  kidneys  are 
calculous,  and  if  but  one  kidney  is  affected,  whether  the  other  is  healthy.  This 
is  to  be  done  by  means  of  the  X-ray  and  tests  of  the  functional  power  of  the 
two  kidneys. 

The  final  diagnosis  of  kidney  calculus,  and  this  is  always  justifiable  when 
the  integrity  of  the  kidney  is  seriously  threatened  and  when  the  patient's  health 
is  progressively  failing,  is  direct  exploration  of  the  kidney  pelvis  by  means  of  a 
lumbar  opening.  When  a  stone  cannot  be  felt,  needling  may  be  resorted  to; 
if  this  be  unsuccessful,  the  pelvis  should  be  opened  and  explored  by  means  of 
finger  and  probe.  WTien  there  is  any  doubt  as  to  the  condition  of  the  remaining 
kidney,  both  organs  should  be  exposed. 

Prognosis. — In  the  absence  of  symptoms  of  obstruction  or  infection  the 
prognosis  of  kidney  stone  is  guardedly  favorable.  Though  the  foreign  body 
may  remain  years  in  the  pelvis  or  calices  of  the  kidney,  causing  no  symptoms 
other  than  occasional  haematuria  or  perhaps  pain,  there  is  a  slow  progression  of 
interstitial  nephritis  which  ultimately  cripples  the  secreting  power  of  the  organ. 
When  obstruction  develops,  if  jt  is  transitory,  due  to  the  passage  of  a  stone 
into  the  bladder,  and  is  completely  relieved  by  the  escape  of  the  calculus,  the 
urine  not  persistently  showing  albumin  and  hyaline  casts,  the  prognosis  is  still 
favorable.  When  the  obstruction  is  not  promptly  relieved,  but  becomes  chronic, 
with  recurring  acute  exacerbations,  the  prognosis  as  to  the  integrity  of  the 
kidney  is  grave.  WTien  infection  takes  place,  the  prognosis  is  always  grave 
unless  prompt  operation  is  practised.  The  combination  of  obstruction  and  infec- 
tion imperatively  calls  for  operative  interference. 

Treatment. — The  preventive  treatment  of  kidney  calculus  is  indicated  when 
the  passage  of  sand  or  gravel,  or  a  microscopic  examination  of  the  urine,  shows 


^28  GENITO-URINARY  SURGERY 

that  there  is  an  excess  of  soHd  constituents.  In  case  the  sediment  or  sand  is 
made  up  of  uric  acid,  out-of-door  exercise,  abstinence  from  alcoholic  drinks, 
baths  and  surface  friction,  careful  regulation  of  the  diet,  and  the  ingestion  of 
large  quantities  of  water,  particularly  Carlsbad,  Friederichshall,  and  London- 
derry, are  indicated. 

When  the  sediment  is  made  up  of  calcium  oxalate,  in  addition  to  exercise, 
diet,  and  diluents,  acid  sodium  phosphate  is  of  service.  Likewise  all  other 
deposits  from  alkaline  urine  require  treatment  directed  either  against  alkaline 
dyspepsia  or  local  infection. 

Patients  subject  to  lithiasis  should  eat  sparingly,  should  especially  avoid 
dark  meats,  sugars,  highly  seasoned  food,  rhubarb,  tomatoes,  asparagus,  and 
strawberries,  Burgundy,  champagne,  and  malt  liquors.  They  should  drink 
freely  of  pure  waters,  which  by  decreasing  the  proportion  of  salts  in  the  urine 
lessen  the  formation  of  new  calculous  material,  and  by  increasing  the  volume 
.of  urine  aid  in  the  discharge  of  any  that  has  already  been  deposited  in  the 
kidney.  Potassium  citrate,  lithium  carbonate,  and  sodium  phosphate  are  the 
most  valuable  alkaline  diuretics.  These  drugs  may  be  given  in  doses  of  from 
five  to  twenty  grains  three  to  six  times  a  day  well  diluted.  Moderate  exercise 
is  highly  desirable,  but  it  should  not  be  carried  to  the  point  of  extreme  fatigue 
or  excessive  perspiration.  All  excesses  should  be  avoided,  especially  those  which 
may  be  followed  by  gastro-intestinal  or  hepatic  disturbances. 

Palliative  treatment  for  severe  pain,  particularly  that  characteristic  of  renal 
colic,  is  mainly  limited  to  the  free  use  of  anodynes  (see  under  "  Diseases  of  the 
Ureter,"  p.  578). 

Nephrolithotomy. — The  absolute  indication  for  the  performance  of 
nephrolithotomy  is  the  presence  of  a  stone  in  the  renal  pelvis  or  its  branchings 
too  large  to  pass  through  the  ureter  into  the  bladder.  Such  a  condition,  proved 
by  the  X-ray,  is  suggested  by  harassing,  persistent  pain,  with  frequent  over- 
whelming exacerbations,  hydronephrosis,  pyonephrosis,  hyaline  casts,  albumen 
in  the  urine,  and  anuria.  The  route  chosen  is,  with  few  exceptions,  the  lumbar 
one.  The  single  advantage  presented  by  the  abdominal  incision  is  that  it  allows 
of  exploration  of  both  kidneys.  The  incision  for  exposing  the  kidney  is  that 
already  described  ( Figs.  316  and  317).  The  patient  is  placed  either  on  his  sound 
side  in  the  half  ventral  decubitus  with  a  roll  beneath  the  loin,  or  in  the  full 
ventral  decubitus  with  Edebohls's  air-cushion  eight  inches  in  diameter  lying  with 
its  centre  of  maximum  pressure  a  little  above  the  umbilicus.  The  incision  is 
carried  from  the  angle  made  by  the  twelfth  rib  and  the  erector  spinae  muscle — 
i.e.,  from  the  lower  border  of  the  twelfth  rib  two  inches  from  the  middle  line 
of  the  back,  downward  and  forward  for  four  inches,  parallel  to  the  rib  and 
toward  the  umbilicus,  cross-cutting  the  anterior  portion  of  the  latissimus  dorsi, 
and  the  upper  part  of  the  serratus  posticus  inferior;  partially  splitting  and 
obliquely  cross-cutting  the  external  and  the  internal  oblique  muscles.  Between 
the  latter  and  the  transversalis  (lumbar)  fascia  the  last  dorsal  nerve  and  inter- 
costal artery  are  usually  encountered;  the  former  should  be  preserved  if  pos- 
sible. The  outer  border  of  the  quadratus  lumborum  muscle  is  then  retracted 
and  the  anterior  layer  of  the  lumbar  fascia  and  the  fascia  transversalis  are 
transversely  split,  exposing  the  fatty  capsule.     If  the  first  incision  does  not 


NEPHROLITHIASIS 


629 


allow  of  full  exposure  of  the  kidney  to  both  palpation  and  inspection,  and  this 
is  possible  only  when  it  is  large  enough  to  admit  the  surgeon's  hand,  it  should 
be  enlarged  both  upward  and  downward,  the  last  rib  being  freed  and  retracted 
or  broken,  or  excised  as  needful.  The  perinephric  fat  is  opened  widely,  and 
the  kidney  is  thoroughly  exposed  through  its  entire  surface  and  is  drawn  well 
into  the  wound  by  traction  on  the  perinephric  capsule,  supplemented,  when  the 
ventral  decubitus  and  the  air-cushion  are  used,  by  so  pulling  the  patient's 
ankles  that  the  air-cushion  placed  beneath  the  abdomen  is  rolled  from  below 
upward  (see  p.  316).  The  kidney  is  then  palpated  by  the  fingers  of  the  two 
hands  placed  on  either  side,  special  attention  being  devoted  to  the  hilum  and 
to  the  two  extremities.  If  the  calculus  cannot  be  detected  by  this  means, — 
and  "this  may  well  be  the  case,  since  even  after  the  kidney  has  been  removed 
from  the  body  palpation  has  failed  to  detect  a  stone  in  its  substance, — an 
incision  should  be  made  through  the  kidney-substance.  The  incision  which 
will  cause  the  least  possible  hemorrhage  must  be  made  in  the  line  of  separation 


■post 


Fig.   336. — A.   The  proper   position   for   the  incision.      (Brodel.)      B. 
Brodel's  wiiite  line. 


of  the  two  vascular  systems  and  must  not  be  angled  towards  the  centre  of  the 
kidney  (Figs.  309  and  336).  Usually  this  vascular  area  lies  parallel  to 
Brodel's  white  line  and  one  centimetre  away  from  it  towards  the  posterior  sur- 
face of  the  organ  (Fig.  337).  The  bleeding  is  often  alarmingly  profuse,  but 
is  usually  checked  by  packing  or  the  use  of  hot  water.  The  kidney  pedicle 
may  previously  be  clamped  either  by  the  fingers  of  an  assistant,  by  a  padded 
clamp  made  for  the  purpose,  or  by  means  of  a  strip  of  rubber  dam  used  as  a 
tourniquet,  but  this  is  not  essential.  The  incision  should  be  large  enough  to 
permit  the  finger  to  be  introduced  into  the  pelvis.  The  cavity  of  the  latter 
can  now  be  thoroughly  explored,  and  this  exploration  may  be  aided  at  times 
by  a  metal  sound.  This  instrument,  however,  must  be  used  with  great  care. 
Preceding  incision  doubt  in  regard  to  the  position  of  the  calculus  may  be  re- 
moved by  means  of  exploratory  punctures  with  a  fine  paper-pointed  needle. 
Kelly  advises  distention  of  the  renal  pelvis  by  means  of  a  ureteral  catheter  and 
an  antiseptic  solution  before  opening  into  its  substance.  Thus  Brodel's  line 
is  made  more  prominent,  and  sacculations  of  the  cortex  may  be  more  readily 
detected.     The  gush  of  fluid  also  denotes  that  the  pelvis  has  been  opened. 


630 


GENITO-URINARY  SURGERY 


The  pelvis  and  calyces  are  explored  by  a  stone-searcher,  such  as  is  used  for  the 
exploration  of  the  bladder  of  children.  After  exploration  of  the  calyces  and 
pelvis,  the  ureter  should  always  be  examined  by  means  of  a  ureteral  catheter. 

The  stone,  having  been  found,  is  readily  removed,  provided  it  be  small  and 
fairly  regular  in  shape.  For  this  purpose  either  the  scoop  or  forceps  is  employed. 
Branching,  coral-like  stones  may  require  fragmentation.  Stones  deeply  placed 
in  the  pelvis  may  be  thrust  up  by  pressure  of  the  fingers  working  from  the 
outside.    Mortar-like  concrements  may  be  removed  by  the  douche  and  scoop. 

After  extracting  the  entire  calculus  it  is 
well  to  flush  out  the  pelvis  and  calyces  with 
a  stream  of  normal  saline  solution  flowing 
under  strong  pressure  (eight  feet)  from  a 
comparatively  large  nozzle.  The  kidney- 
wound  is  then  sutured,  usually  by  No.  2 
mattress  chromicized  or  iodized  catgut 
passed  through  the  capsule  and  kidney-sub- 
stance down  to  the  pelvis  or  the  walls  of  a 
dilated  calyx,  but  not  including  the  mucous 
membrane  (Fig.  338).  These  sutures  are 
tied  down  with  moderate  tension,  and,  pro- 
viding they  have  been  placed  deeply,  effec- 
tually stop  bleeding.  The  kidney-wound  is 
not  drained.  The  parietal  wound  is  closed 
by  careful  suture  of  the  muscles  with  chromi- 
cized catgut.  A  drainage-tube  should  be 
carried  to  the  kidney-wound  in  the  majority 
-P  of  cases. 

Pyelotomy. — In  the  majority  of  cases 
it  is  possible  to  remove  stones  from  the  kid- 
ney through  an  opening  in  its  pelvis  without 
cutting  the  parenchyma  of  the  organ.  For 
the  performance  of  this  operation  the  kidney 
must  be  delivered  and  the  posterior  surface 
of  the  pelvis  exposed  and  freed  from  fat.  A 
longitudinal  incision  is  then  made,  care 
being  taken  not  to  injure  a  large  vessel 
which  commonly  crosses  the  pelvis  just 
within  the  hilum.  The  stone  or  stones  hav- 
ing been  removed  by  means  of  forceps,  and  the  ureter  explored,  the  wo'und  in 
the  pelvis  is  closed  with  a  few  catgut  sutures,  thereafter  reinforced  by  a  second 
line  of  sutures  approximating  the  fibro-fatty  investment,  the  kidney  replaced, 
and  the  parietal  wound  closed  in  the  usual  manner. 

When  the  secreting  substance  of  the  kidney  has  disappeared  and  is  repre- 
sented simply  by  a  sac  in  which  a  large  calculus  is  contained,  nephrectomy  is 
indicated.  If  there  be  doubt  as  to  the  condition  of  the  opposite  kidney  this 
may  be  performed  as  a  second  operation, — i.e.,  some  weeks  or  months  after 
removal  of  the  stone,  and  after  taking  every  means  of  making  certain  tliat  the 
other  kidney  is  competent  to  act  for  both. 


Fig.  337. — Lateral  view  of  kidney.  6-6', 
Brodel's  white  line;  a-a',  mid-line  of  kidney; 
c-c',  line  of  incision.     (Brodel.) 


NEPHROLITHIASIS  631 

When  infection  has  taken  place,  the  parietal  incision  is  the  same  as  that- 
for  nephrolithotomy,  but  the  incision  into  the  kidney  is  made  at  the  thinnest 
and  most  accessible  portion  of  the  tumor.  Since  infection  is  usually  complicated 
by  pyonephrosis,  there  may  be  a  large  sac  with  diverticula,  making  the  finding 
and  removal  of  a  stone  extremely  difficult.  It  is  in  these  cases  particularly  that 
the  sound  is  serviceable.  It  often  happens  that  the  calculi  are  either  not  found 
at  all,  or,  if  found,  are  only  in  part  removed. 

In  the  after-treatment  of  these  wounds  lumbar  drainage  is  always  indicated. 
Fistulse  are  prone  to  persist  in  the  track  of  the  drainage-tubes. 

When  stones  exist  in  both  kidneys  Mayo  -  advises  operating  first  on  the 
side  -wdth  the  better  function;  the  worse  side  may  demand  nephrectomy,  or 
operation  may  be  found  to  be  unnecessary  when  the  trouble  in  the  better  kidney 
has  been  remedied.    Kidneys  badly  disorganized  by  infection  are  best  removed 


Fig.  338. — Method  of  suturing  split  kidney. 

when  the  function  on  the  opposite  side  is  adequate,  as  a  recurrence  of  stones  is 
frequently  noted  in  such  cases.  When  conservatism  is  needful,  the  pelvis  should 
be  drained  by  means  of  a  tube  passed  through  the  kidney-substance,  while  those 
calyces  which  approach  the  surface  should  be  incised  and  drained  separately 
(tubes .or  cigarette  drains). 

Nephrolithotomy  performed  before  the  advent  of  suppuration  is  attended 
by  a  mortaHty  of  less  than  four  per  cent.  After  suppuration  the  mortality  is 
much  greater,  and  a  large  percentage  of  cases  are  troubled  by  permanent  fistula. 

It  frequently  happens  that  persistent  renal  symptoms,  particularly  haema- 
turia,  pain,  and  recurrent  colic,  are  entirely  cured  by  nephrotomy,  even  though 
no  stone  or  other  cause  for  symptoms  be  found  at  operation.  This  is  so  well 
recognized  that  the  operation  is  indicated  by  the  wearing  persistence  of  symp- 
toms which  do  not  yield  to  conservative  treatment. 

^Surgery,  Gynecology  and  Obstetrics,  1917,  xxiv,  1. 


CHAPTER  XXVIII 

RENAL  INFECTIONS 

The  suppurative  diseases  of  the  kidney  may  be  arranged  in  two  groups.  In 
the  first  group  belong  those  suppurations  the  microbes  of  which  enter  the  kidney 
through  the  artery,  vein,  or  lymphatic  channels,  or  extend  by  contiguity  from 
the  perinephric  tissue.  In  the  second  group  are  those  suppurations  which  are 
due  to  ascending  infection  along  the  ureter. 

Haematogenous  infection  of  the  kidney  is  nearly  always  secondary  to  pyo- 
genic foci  elsewhere,  such  as  furuncle,  carbuncle,  tonsillar  abscess,  and  parotitis; 
septic  material  ascending  the  vena  cava  may  enter  the  kidney  and  produce 
suppuration.  Exceptionally  it  is  impossible  to  locate  a  primary  focus;  in  such 
cases  we  must  assume  that  microorganisms  circulating  in  the  blood  have  attacked 
the  kidneys  first. 

Traumatic  suppuration  of  the  kidney,  unless  the  result  of  a  penetrating 
wound,  must  be  classed  with  haematogenous  infections,  since,  in  the  absence  of 
bacteria,  concussion  or  contusion  of  tissue  cannot  produce  suppuration.  It  is 
evident,,  however,  that  the  injury  prepares  a  suitable  culture-field  for  circulating 
microorganisms. 

It  is  often  impossible  to  distinguish  between  lymphatic  infection  and  infec- 
tion due  to  extension  by  contiguity.  As  causes  of  secondary  infection  may  be 
mentioned  appendicitis,  perityphlitis,  parametritis,  caries  of  the  vertebrae, 
sacrum,  or  pelvis,  deep  colonic  ulceration,  abscess  of  the  liver  or  spleen,  sub- 
phrenic abscess,  and  urinary  infiltration  (rare).  All  these  inflammations  may 
extend  to  the  kidney,  involving  both  this  gland  and  its  fatty  capsule. 

The  microorganisms  commonly  causative  of  renal  suppuration  are  the  mem- 
bers of  the  colon  group,  the  micrococcus  aureus,  the  streptococcus  pyogenes, 
and  the  proteus  Hauseri.  Exceptionally  infection  is  due  to  the  gonococcus,  the 
bacillus  typhosus,  the  diplococcus  pneumoniae,  the  bacillus  ulceris  cancrosi,  the 
bacillus  of  Friedlander,  the  bacterium  pseudotuberculosis  rodentium,  the  tubercle 
bacillus,  actinomyces,  and  the  microorganisms  of  acute  infectious  diseases.  It 
should  be  borne  in  mind  that  pyelitis  is  common  in  the  course  of  the  various 
infectious  diseases,  and  may  become  membranous. 

Several  facts  must  be  emphasized  in  relation  to  the  renal  suppurations  which 
result  from  ascending  infection.  Obstruction  in  the  urethra,  bladder,  or  ureter 
which  interferes  with  the  outflow  of  urine  produces  conditions  favorable  to 
infection,  though  it  will  not  in  itself  cause  suppuration.  An  aseptic  ligation 
of  one  ureter  causes  atrophy  of  the  kidney,  but  a  septic  ligation  gives  rise  to 
suppuration.  Traumatism,  alteration  in  the  character  of  the  urine,  or  the  elimi- 
nation of  irritating  drugs,  such  as  cantharides,  produces  congestion,  but  never 
septic  inflammation.  All  causes  which  occasion  acute  or  chronic  congestion 
predispose  to  infection.  There  is  some  uncertainty  as  to  the  manner  in  which 
infections  in  the  bladder  spread  to  the  kidney,  experimental  work  seeming  to 
show  that  in  many  instances  it  takes  place  through  the  paraureteral  lymphatics. 
632 


RENAL  INFECTIONS  (^^T, 

Clinically,  obstruction  and  the  consequent  alterations  in  the  urine  are  the 
conditions  which  most  frequently  render  the  kidney  and  its  excretory  channels 
favorable  culture-media  for  pyogenic  microorganisms.  As  a  rule,  the  healthy 
mucous  membrane  of  the  urogenital  tract  resists  septic  infection,  but  it  will  not 
always  do  so,  nor  is  it  necessary  that  there  should  be  obstruction  in  order  that 
septic  matter  in  the  bladder  may  infect  the  pelvis  of  the  kidney.  Under  certain 
circumstances  intestinal  bacteria  may  obtain  an  entrance  into  the  kidneys  with- 
out any  discoverable  break  in  the  continuity  of  the  tissues. 

The  methods  by  which  bacteria  may  reach  the  kidneys  from  below  are — 
through  the  urine;  by  extension  along  the  mucous  membrane  or  the  lymph- 
channels  of  the  ureters;  by  penetration  into  the  pelvis  or  ureter  from  the  tissues 
surrounding  the  urinary  tract. 

In  accordance  with  its  location  and  clinical  course  renal  suppuration  is 
termed  pyelitis,  pyonephrosis,  pyelonephritis,  suppurative  nephritis,  and  peri- 
nephritis. 

Pyelitis,  or  inflammation  of  the  kidney  pelvis,  may  be  secondary  to  nephritis 
(descending),  or  to  ureteritis  (ascending),  or  rarely  to  perinephritis  (contiguity) ; 
the  ascending  inflammation  is  the  common  form. 

The  most  frequent  predisposing  andexciting  causes  of  pyelitis  are — {a)  the 
infectious  diseases;  whether  in  these  cases  the  local  inflammation  is  due  to 
microorganisms,  toxins  or  alterations  in  the  urine  has  not  been  determined;  {b) 
traumatism,  a  rare  but  undoubted  cause;  (c)  exposure  to  cold;  (d)  drug,  irrita- 
tion, as  from  the  irritating  diuretics,  the  balsams,  the  ethereal  oils;  (e)  nephritis, 
particularly  the  interstitial  nephritis  of  the  gouty;  (/)  venous  congestion,  due 
either  to  general  stasis  or  to  local  stasis,  as  in  chronic  valvuHtis,  pregnancy, 
movable  kidney,  abdominal  tumor;  (g)  perinephric  inflammation;  (k)  mechani- 
cal irritation  of  gravel  or  calculus;  (/')  tubercle,  malignant  disease,  parasites; 
(;)  and,  most  important  of  all,  cystitis,  particularly  when  it  is  associated  with 
obstruction. 

Pyelitis  is  usually  bilateral.  It  varies  in  degree  from  a  superficial  catarrhal 
inflammation  to  a  deep  infiltrating  destructive  process.  In  the  absence  of 
infection  there  is  often  a  congestion  of  the  mucous  membrane  of  the  pelvis  un- 
associated  with  desquamation  of  epithelium  or  suppuration.  Such  a  condition 
may  be  caused  by  irritating  conditions  of  the  urine. 

Catarrhal  pyelitis  may  be  acute  or  chronic.  In  the  acute  form  the  mucous 
membrane  is  swollen  and  congested;  there  are  patches  of  desquamation;  in 
severe  cases  the  surface  is  covered  with  thick  mucus  mixed  with  blood,  in  which 
the  crystals  of  the  urinary  salts  are  deposited.  In  chronic  pyelitis  the  mucous 
membrane  is  dark  in  color,  there  is  a  serous  infiltration  of  the  submucoid  tissues, 
with  interstitial  overgrowth,  many  small  mucus-cysts  may  be  formed,  and  in  some 
cases  the  lymph-follicles  become  much  enlarged  and  prominent  (pyelitis  granu- 
losa) (Fig.  339).  The  surface  is  often  covered  with  a  tenacious  altered  mucus, 
and  there  is  general  desquamation  of  epithelium.  Ulceration  may  be  present, 
which  may  extend  through  the  coats  of  the  pelvic  wall,  giving  rise  to  abscesses 
or  even  to  infiltration  of  urine.  Any  pyelitis  may  become  membranous,  par- 
ticularly when  ammoniacal  fermentation  has  taken  place.  Indeed,  a  strictly 
catarrhal  pyelitis  is  rare. 


634 


GEXITO-URINARY  SURGERY 


\Mien  the  pus  of  pyelitis  blocks  a  ureter,  pyonephrosis  or  pyelonephritis 
results.  Parenchymatous,  or  more  commonly  interstitial,  nephritis  is  frequently 
caused  by  pyelitis;  the  contracted  kidney  of  pyelitis,  however,  differs  from  a 
primary  contracted  kidne}^  in  that  the  preponderance  of  fibrous  overgrowth  is 
in  the  medullar}'  substance  instead  of  in  the  cortex.  Amyloid  degeneration  may 
occur  in  one  or  both  kidneys  when  suppuration  is  profuse  and  long  continued. 

Symptoms. — In  many  cases,  as  is  evident  from  the  list  of  causes,  the  symp- 
toms of  a  pyelitis  are  lost  in  those  of  the  antecedent  disease.  In  simple  con- 
gestion of  the  pehds  pain  in  the  loins  and  frequent  urination  are  the  only 
symptoms. 


Fig.  339. — Pyonephrosis.  Observe -the  dilatation  of  the  calyces  and 
note,  furthermore,  the  chronic  granulations  covering  the  mucosa  (pyelitis 
granulosa).  (From  the  Laboratory  of  Surgical  Pathology,  University  of 
Pennsylvania.) 

In  acute  catarrhal  purulent  pyelitis  the  pain  is  often  severe,  and  may 
present  acute  exacerbations;  the  kidneys  are  tender  on  pressure,  and  frequency 
of  urination  is  marked.  The  quantity  of  urine  is  usually  decreased,  and  excep- 
tionally reflex  anuria  may  supervene.  The  pain  is  increased  by  motion,  by  deep 
respiration,  or  by  coughing,  and  may  be  reflected  down  into  the  penis  and 
testicle  or  up  towards  the  shoulder. 

Vomiting  is  not  uncommon.  Fever  develops,  and  there  may  be  chills  followed 
by  profuse  perspiration.  As  a  rule,  the  kidneys,  though  tender,  are  not  enlarged 
in  acute  pyelitis. 

The  urine  is  generalh'  acid,  and  contains  a  trace  of  albumen,  degenerated 
epithelium,  and  often  blood  and  h3^aline  casts. 


RENAL  INFECTIONS  635 

Acute  pyelitis  and  pyelonephritis,  due  to  the  colon  bacillus,  are  common, 
though  usually  overlooked,  in  infancy;  pyuria  of  nonvesical  origin,  renal  tender- 
ness, chills,  fever,  and  gastro-intestinal  disturbances  are  characteristic  symptoms. 

In  chronic  pyelitis  the  symptoms  are  usually  less  pronounced.  The  pains 
are  not  so  marked,  nor  are  the  organs  so  tender  on  pressure.  Fever,  if  present, 
is  likely  to  be  intermittent.  The  kidney  is  not  palpably  enlarged  unless  there 
is  pyonephrosis.     There  is  a  general  impairment  of  health. 

The  urine  is  increased  in  amount,  is  acid  or  neutral,  and  contains  nucleo- 
albumen,  pus,  and  epithelium  in  abundance;  blood  is  rare.  As  in  the  acute  form, 
hyaline  casts  are  common,  but  in  a  pure  pyelitis  granular  casts  are  rarely  seen. 
If  only  one  kidney  is  affected,  there  may  be  periods  when,  owing  to  obstruction 
of  the  diseased  pelvis,  the  urine  will  be  normal.  Calculi  not  infrequently  form 
in  chronically  inflamed  pelves.  Many  cases  of  chronic  pyelitis  are  overlooked 
till  irremediable  kidney  disorganization  has  occurred. 

Diagnosis. — Pyelitis  must  be  distinguished  from  renal  and  from  vesical 
inflammation.  In  pyelitis  the  albumen  is  dependent  upon  the  blood  and  pus, 
in  nephritis  it  is  essential.  Granular  casts  are  usual  in  kidney  disease,  they 
are  not  found  in  pyelitis.  The  large  amount  of  nucleo-albumen  is  quite  dis- 
tinctive of  pyelitis.  The  leucocytes  in  the  urine  of  nephritis  are  often  mononu- 
clear, those  of  pyelitis  are  polynuclear.  The  pain  of  nephritis  is  insignificant, 
while  acute  severe  pain  occurs  in  nearly  all  cases  of  pyelitis.  The  differential 
diagnosis  between  pyelitis  and  pyonephrosis,  or  pyelonephritis,  or  acute  sup- 
purative nephritis  is  in  some  cases  impossible,  though  the  greater  tendency  to 
marked  constitutional  symptoms  and  palpability  when  the  kidney  proper  is 
involved  usually  serves  to  differentiate  the  latter  from  pyelitis. 

Cystitis  suppurates  more  freely  than  pyelitis,  and  the  urine  is  more  likely 
to  be  alkaline  and  contains  a  much  smaller  percentage  of  albumen  (one-tenth 
per  cent.,  as  contrasted  with  three  times  as  much  in  pyelitis.  Rosenfeld).  A 
cystoscopic  examination  will  prove  the  presence  of  inflammation,  and  ureteral 
catheterization  wifl  show  that  the  urine  contains  no  pus  till  it  reaches  the 
bladder.  Such  an  examination  may  be  required  before  the  origin  of  pus  can 
be  positively  determined.  The  importance  of  this  becomes  evident  when  it  is 
realized  that  in  the  absence  of  ureteral  obstruction  polyuria  and  pyuria  are 
the  most  constant  and  reliable  signs  of  chronic  pyelitis.  Bazy  regards  noc- 
turnal pollakiuria  as  the  most  important  of  all  signs  for  the  differentiation  of 
pyelitis. 

Prognosis. — Acute  congestion  and  chronic  congestion  of  the  kidney  pelvis 
are  dangerous  only  because  they  predispose  to  infection.  Acute  catarrhal  or 
purulent  pyelitis  is  generally  self-limited  unless  the  infection  has  spread  to  the 
kidney-substance,  the  period  of  disease  varying  from  a  few  days  to  a  few  weeks. 
The  prognosis  and  duration  of  chronic  pyelitis  depend  obviously  upon  the 
cause.  When  the  disease  develops  without  appreciable  cause,  or  when  it  is 
associated  with  incurable  obstruction  or  an  inveterate  gouty  diathesis,  the 
prognosis  must  be  suarded. 

Treatment. — The  treatment  of  pyelitis  varies  in  accordance  wath  the  cause, 
and  is  also  dependent  in  a  measure  upon  the  character  of  the  inflammation. 
Slight  cases,  such  as  those  which  develop  after  the  exanthemata,  are  treated 


636  *  GEXITO-URIXARY  SURGERY 

by  rest;  liquid  diet,  and  the  ingestion  of  diluents.  The  natural  tendency  of 
this  form  of  inflammation  is  towards  recovery.  When  the  symptoms  are 
sufficiently  severe  to  excite  some  constitutional  reaction  and  to  cause  local  pain, 
counter-irritation,  local  depletion,  hot  baths,  the  administration  of  soothing  or 
stimulating  diuretics,  and  careful  attention  to  the  condition  of  the  skin  are 
indicated.  Pain  should  be  relieved  by  morphine  given  hypodermically.  Inflam- 
mation due  to  mechanical  causes,  such  as  calculus  or  stricture,  prostatic  enlarge- 
m.ent,  or  any  obstruction  to  the  free  flow  of  urine,  can  be  cured  only  by  surgical 
intervention.  Should  this  become  necessary  in  the  course  of  acute  pyelitis,  it 
must  be  borne  in  mind  that  there  is  always  great  danger  of  converting  a  simple 
P3'eliti3  into  a  pyelonephritis  or  ""  surgical  kidney  ";  hence  every  antiseptic  pre- 
caution should  be  taken. 

If  the  bladder  be  the  seat  of  inflammation,  vigorous  treatment  of  the  cystitis 
may  effect  a  cure.     Cabot  has  pointed  out  the  value  of  the  indwelling  catheter. 

The  operative  procedures  should  be  preceded  by  the  administration  of 
urinan,'  antiseptics, — namely,  salol  and  urotropin  in  full  doses,  the  urine  being 
acid. 

The  development  of  pyelitis  as  a  complication  of  any  obstructive  lesion  of 
the  urinar\'  tract,  regardless  of  its  seat  or  cause,  is  a  sufficient  ground  for  opera- 
tive interference  when  this  offers  any  promise  of  permanently  overcoming  the 
obstruction.  The  operation  should  be  performed  early,  since  pyelitis  associated 
with  obstruction  means  inevitable  destruction  of  the  secreting  substance  of  the 
kidney. 

Kell}',  Pawlik,  and  others  have  treated  chronic  pyeHtis  by  the  mouth  admin- 
istration of  urinary  antiseptics  (salol  and  urotropin)  and  diluents,  and  by 
drainage,  instillation,  and  irrigation.  This  treatment  is  particularly  indicated  in 
cases  developed  as  a  consequence  of  haematogenous  or  of  ascending  infection;  but 
in  the  latter  case  only  after  the  cure  of  the  lesions  of  the  lower  tract.  Protargol, 
in  one  to  five  per  cent,  solution,  is  used  for  instillation,  the  same  drug,  1  to 
2000,  or  boric  acid,  1  to  500,  for  irrigation,  the  treatments  being  repeated  twice 
weekly  till  pus  has  disappeared  from  the  urine.  Thereafter  prolonged  dietetic 
and  hygienic  treatment  is  indicated.  Treatment  with  autogenous  bacterins 
sometimes  produces  brilliant  cures,  and  should  be  tried  before  resorting  to  more 
formidable  measures.  "\Mien,  in  spite  of  medicinal  and  dietetic  treatment,  a 
chronic  pj^elitis  persists,  as  shov>-n  by  urinary  examination  and  renal  and  gastro- 
intestinal symptoms,  pyelotomy  or  nephrotomy  is  indicated.  Mechanical  causes 
of  obstruction  are  sought  for  and  removed,  and  the  pelvis  is  irrigated  and 
drained  through  ureteral  catheters. 

Pyoxepkrosis. — WTien  in  the  course  of  pyelitis  the  ureter  becomes  blocked, 
pyonephrosis  develops.  The  same  condition  is  produced  b}^  infection  of  hydro- 
nephrosis. The  pehis  becomes  rapidly  distended,  and  ulceration  and  dilatation 
of  the  calyces  occur  (Fig.  339).  WTien  the  condition  is  permanent  the  entire 
kidney  is  riddled  with  abscesses.  The  obstruction  is  usually  incomplete;  or  the 
ureter  may  be  completely  blocked  (closed  pyonephrosis),  so  that  there  is  no  pus 
in  the  urine.    Pyo-ureter  is  a  not  infrequent  accompanying  lesion. 

The  pehis  may  rupture  early:  later  rupture  may  take  place  through  the 
cortex;  in  either  case  there  results  a  perinephric  abscess.  Exceptionally  pus 
may  become  inspissated,  and  extreme  contraction  of  the  kidney  occur.     Pyo- 


RENAL  INFECTIONS 


637 


nephrosis  may  give  rise  to  general  metastasis,  but  this  is  rare.  Occasionally 
adhesions  to  neighboring  organs  are  formed  and  rupture  into  them  takes  place. 

Symptoms. — In  cases  which  follow  the  blocking  of  a  ureter  the  first  symp- 
tom is  usually  pain,  which  may  be  colicky,  and  is  made  worse  by  pressure,  par- 
ticularly when  it  is  applied  from  in  front.  Chill  and  fever  commonly  herald  the 
occurrence  of  suppuration  in  a  hydronephrotic  sac.  The  quantity  of  urine  bears 
some  ratio  to  the  retention;  anuria  may  be  produced  by  reflex  inhibition,  though 
this  is  usually  due  to  defect  or  absence  of  the  other  kidney. 

A  tumor  may  form  in  the  loin,  tender  on  pressure,  fluctuating  in  most  cases, 
but  sometimes  doughy,  and  projecting  into  the  abdominal  cavity.  The  tumor 
is  often  not  perceptible.  Percussion  in  the  flank  gives  a  dull'  note,  but  the 
presence  of  the  overlying  colon  generally  suffices  to  make  the  note  on  abdominal 
percussion  resonant;  alternate  emptying  and  filling  of  the  colon  with  air  or  liquid 
may  aid  in  establishing  a  diagnosis. 


Fig.  340. — Operation  of  nephrotomy.  The  kidney-wound  has  been 
closed  by  deep  and  superficial  interrupted  sutures  around  the  large  rubber 
drainage-tube  introduced  into  the  renal  pelvis.  Lumbar  muscles  and  skip 
being  closed. 

Pus  may  temporarily  disappear  from  the  urine  (unilateral  involvement  and 
obstruction).  A  sudden  reduction  of  pus  in  the  urine' does  not  imply  obstruction 
unless  it  is  coincident  with  a  reduction  in  the  quantity  of  urine.  If  the 
obstruction  is  permanent  and  the  other  kidney  is  able  to  compensate,  the 
quantity  of  urine  will  gradually  rise  to  the  normal. 

Irregular  fever,  with  a  high  evening  rise,  chills,  and  the  constitutional 
symptoms  of  internal  suppuration  are  present  in  most  cases,  but  some  run  their 
course  with  few  or  no  general  symptoms.  Leucocytosis  is  present  in  at  least  the 
early  stages  of  the  disease. 

Diagnosis. — The  diagnosis  of  pyonephrosis  is  founded  upon  the  presence 
of  a  tumor  in  the  region  of  the  kidney  and  on  intermittent  pyuria.  The  tumor 
cannot  always  be  felt,  since  distention  may  take  place  upward  towards  the 
diaphragm.  When  perceptible  it  is  rounded  in  form,  obscurely  fluctuating,  and 
tender  on  pressure.  A  characteristic  of  the  tumor  is  its  variation  in  size,  de- 
pendent upon  temporary  relief  of  obstruction  and  escape  of  the  purulent  urine 
contained  in  the  kidney  pelvis.    This  symptom  is  closely  related  to  intermittent 


638 


GENITO-URINARY  SURGERY 


pyuria;  when  but  one  kidney  is  affected,  the  other  remaining  healthy,  there 
may  be  periods  when  the  urine  is  absolutely  normal,  followed  by  periods  during 
which  there  is  marked  polyuria,  the  urine  containing  a  large  quantity  of  pus; 
that  with  "  closed  "  pyonephrosis  the  urine  may  be  continuously  clear  has 
already  been  noted. 

Rayer  states  that  pyonephrosis  must  be  distinguished  from  morbid  enlarge- 
ments of  the  spleen,  liver,  and  gall-bladder,  from  renal  tumors  due  to  causes 
other  than  pyonephrosis,  such  as  hydronephrosis,  hemorrhage,  tumor,  tubercle, 
or  cysts,  from  renal  abscess,  from  tumors  of  the  suprarenal  capsule,  from  aortic 
aneurism,  and  from  fsecal  impaction. 


Fig.  341. — -Watson's  nephrostomy  apparatus. 

A  differentiation  from  hydronephrosis  or  perinephric  abscess  is  often  difficult. 
Hydronephrosis  is  unattended  by  fever,  and  there  is  usually  but  slight  pain; 
pyuria  is  absent.  Perinephric  abscess  is  characterized  by  severe  pain,  rapid 
extension  of  the  tumor,  marked  constitutional  symptoms,  extreme  local  tender- 
ness, and  often  oedema  and  superficial  fluctuation.  The  urine  may  or  may  not 
contain  pus;  the  thigh  is  often  flexed  upon  the  abdomen.  At  times  a  distinction 
cannot  be  made.  This,  however,  is  not  a  matter  of  great  importance,  since 
the  three  conditions,  pyonephrosis,  perinephric  abscess,  and  hydronephrosis, 
practically  require  the  same  treatment. 


RENAL  INFECTIONS 


639 


Treatment. — Pyonephrosis,  dependent  as  it  necessarily  is  upon  infection 
and  obstruction,  is  amenable  only  to  mechanical  treatment.  Ureteral  catheteri- 
zation will  relieve  tension,  and  hence  stop  septic  absorption,  and  enable  the 
surgeon  to  perform  pelvic  irrigation  and  instillation. 

An  obstruction  which  cannot  be  remedied  by  position  or  catheterization  calls 
for  operation,  for  immediate  operation  when  septic  symptoms  are  prominent. 

Exceptionally  the  kidney  atrophies,  the  pus  which  it  contains  becomes 
caseous,  and  there  is  thus  effected  a  species  of  spontaneous  cure. 

The  operative  treatment  may  take  the  form  of  nephrotomy,  nephrostomy,, 
or  nephrectomy. 

The  choice  between  the  three  procedures  depends  in  part  upon  the  condition 
of  the  kidney  operated  upon,  and  in  part  on  the  condition  of  its  mate.  Obvi- 
ously it  is  not  permissible  to  do  a  nephrectomy  when  the  opposite  kidney  is 
not  functionally  competent  to  withstand  the  strain  of  a  double  burden;   and 


Fig.  342. — Operation  of  nephrostomy.  First  step:  kidney 
anchored  in  lumbar  wound  by  placement  of  two  sutures  near  polar 
extremities  of  renal  incision;  cut  edges  of  kidney  sutured  to  lumbar 
muscles. 

just  as  obviously  it  is  the  duty  of  the  surgeon  to  ascertain  as  nearly  as  may  be 
the  condition  of  the  opposite  organ  before  exposing  a  pyonephrotic  kidney. 

When  the  ureteral  obstruction  can  be  removed,  and  the  damage  to  the  kidney 
structure  is  not  irremediable,  nephrotomy,  with  exploration  of  the  pehis  for 
stone,  evacuation  of  the  contained  pus,  the  removal  of  the  obstruction,  and 
the  insertion  of  a  tube  drain  (Fig.  340)  is  the  operation  of  choice.  When, 
because  of  the  character  of  the  obstruction  or  the  extent  of  the  damage  already 
done,  it  is  unreasonable  to  hope  for  a  cure  of  the  infection  the  kidney  should 
be  removed,  provided  its  mate  is  in  sufficiently  good  condition. 

Nephrectomy  may  be  performed  either  as  a  primary  or  as  a  secondan,'  opera- 
tion; statistics  for  the  former  are  overwhelmingly  in  its  favor. 

Nephrostomy. — The  object  of  this  operation  is  to  create  a  fistula  of  as  large 
size  as  possible  through  the  kidney- substance  to  the  pelvis,  best  kept  open  by  a 
silver  tube.  Some  sort  of  receptacle  must  be  worn  to  receive  the  urine,  and 
for  this  purpose  the  one  devised  by  Watson  is  the  most  convenient  (Fig.  341). 

The  ooeration  is  performed  by  exposing  the  kidney  through  a  loin  incision 


640 


GEXITO-URIXARY  SURGERY 


(freeing  it  as  little  as  possible  from  its  fatt}-  capsule),  and  incising  it  either 
one  centimetre  back  of  Brodel's  line  or  through  the  thinnest  part  of  the  paren- 
chyma into  the  pelvis.  The  circumference  of  the  kidney  wound  is  then  sewn 
to  the  fascia  and  a  drainage-tube  surrounded  by  gauze  packing  inserted  into 
the  pelvis  (Figs.  342  and  343).  If  pus  has  escaped  into  the  surrounding  fascia, 
this  region  should  be  drained,  ^^^len  the  operation  is  performed  as  a  pre- 
liminary- to  cystectomy,  the  ureter  should  be  ligated  and  di\aded. 

Pyelonephritis. — This  term  signifies  septic  inflammation  of  the  kidney 
secondan,-  to  pyelitis.  It  is  the  ascending  form  of  renal  suppuration:  the  de- 
scending form  is  best  known  as  suppurative  nephritis. 

The  predisposing:  and  exciting  causes  of  pyelonephritis  are  the  same  as  those 
of  pyelitis  and  pyonephrosis.  It  is  merely  a  more  extensive  and  more  dangerous 
stage  of  pyelitis,  and  an  almost  unavoidable  complication  of  pyonephrosis.    The 


Fig.   343. — Operation  of  nephrostomy.     Second  step:  cortex 
-  of  kidney  and  luxnbar  muscles  being  sutured  to  the    skin;   drainage- 
tube  in  position. 

infection  extends  from  the  calyces  into  the  uriniferous  tubules,  involving  the 
parenchyma  of  the  kidney,  and  converting  the  organ  into  a  mass  of  small  ab- 
scesses (Fig.  344),  or  perhaps  one  large  suppurating  sac.  The  name  '•  surgical 
kidney  "  has  been  applied  to  this  form  of  suppurative  disease,  because  it  has 
been  so  frequently  produced  by  the  use  of  infected  instruments. 

Pyelonephritis  is  apt  to  develop  rapidly  when  decomposing  urine  is  retained 
in  the  pelvis:  it  may  be  caused  by  extension  of  inflammation  in  the  absence  of 
retention. 

In  the  early  stages  of  pyelonephritis  the  cortex  of  the  kidney  is  thin,  and 
the  capsule  is  adherent  to  the  surface  and  to  the  renal  tissue.  AMien  it  is 
stripped  from  the  kidney  numerous  small  abscesses  are  opened;  the  kidney  is 
swollen,  soft,  and  congested.  Section  shows  yellows  streaks,  the  distended 
straight  tubules  running  from  the  cortex  to  the  pyramids.    Between  these  streaks 


RENAL  INFECTIONS 


641 


the  renal  substance  seems  to  be  healthy.  The  pelvis  is  congested,  and  exhibits 
patches  of  ecchymosis,  or  even  of  ulceration.  Instead  of  small  suppurating  foci, 
large  abscesses  may  form,  and  break  through  the  kidney  capsule. 

Microscopically,  the  straight  tubules  are  dilated,  distorted,  and  filled  with 
epithelial  debris,  pus,  urinary  salts,  and  microorganisms.  The  veins  are  also 
distended  with  partially  coagulated  blood  and  pus.  (This  is  in  marked  contrast 
with  pyzemic  processes,  in  which  the  blood-clot  and  pus-formation  take  place 
within  the  arteries.)  The  Malpighian  bodies  and  convoluted  portions  of  the 
tubules  become  obliterated.  The  fatty  capsule  is  infiltrated,  tough,  fibrous, 
and  adherent  in  chronic  inflammation,  or  it  may  become  infected  and  suppurate. 

The  colon  bacillus  is  the  usual  microbic  cause  of  an  ascending  pyelonephritis. 


Small  abscesses  stud- 
ding the  markedly 
diseased  parenchyma 


Pelvis  of  kidney 
covered  with 
inflammatory 
exudate 


Fig.     344. — Pyelonephritis.       (Laboratory    of    Surgical     Pathol- 
ogy, University  of  Pennsylvania.) 

Symptoms. — Pyelonephritis  may  assume  the  acute  or  the  chronic  form. 
The  acute  form  is  characterized  by  the  suddenness  of  its  onset,  a  chill,  followed 
by  high  fever,  and  accompanied  by  severe  pains  in  the  loins  being  the  usual 
sequence.  There  is  often  delirium,  and  the  fever  may  rise  to  106°,  107"  F.,  or 
even  higher. 

Usually  the  fever  is  continuous,  with  remissions.  The  patient  passes  into  a 
typhoid  state;  the  tongue  is  dry  and  heavily  coated;  there  is  rapid  emaciation, 
and  often  an  extremely  irritable  condition  of  the  stomach,  and  drenching  sweats. 
There  may  be  persistent  vomiting  and  hiccough.  Mental  dulness,  semi-con- 
sciousness deepening  into  coma,  and  finally  death,  follow. 

The  disease  is  usually  rapidly  fatal,  termiinating  in  about  ten  days  or  two 
weeks.  It  is  obvious  that  symptoms  of  acute  pyelonephritis  are  due  in  part  to 
septic  intoxication,  in  part  to  renal  insufficiency. 

All  cases  do  not  end  fatally.  The  fever  may  gradually  grow  less,  the  stomach 
become  retentive,  and  a  return  to  comparative  health  follow.  In  such  cases  it 
seems  probable  that  the  pus  has  been  so  placed  as  to  be  well  drained  into  the 


41 


642  GENITO-URINARY  SURGERY 

ureter,  or  that  it  has  become  caseous  and  encysted,  the  secreting  substance  of 
the  one  kidney  having  been  destroyed,  and  the  remaining  kidney  having  assumed 
double  duty. 

With  the  lessening  or  disappearance  of  fever  the  return  to  health  is  the  ex- 
ception, not  the  rule.  The  pyelonephritis  is  more  likely  to  become  chronic. 
In  this  form  of  inflammation  the  temperature  may  be  normal.  Commonly  it 
is  slightly  and  persistently  elevated. 

Rayer  long  ago  pointed  out  that  the  chief  symptoms  of  chronic  pyelone- 
phritis are  often  those  of  gastro-intestinal  irritation:  chronic  dyspepsia,  a  dry 
brown  tongue,  secretion  of  saliva  so  scanty  that  solid  food  is  refused,  con- 
stipation, often  tympany,  sometimes  uncontrollable  diarrhoea.  The  patient  is 
usually  extremely  weak  and  depressed,  and  sleeps  badly.  These  symptoms 
gradually  become  more  marked,  and  progressive  emaciation,  extreme  suscepti- 
bility to  local  congestion  from  exposure  to  cold,  and  frequently  intercurrent 
febrile  attacks,  develop.  Locally  there  may  be  neither  pain  nor  tumor,  and 
the  patient  may  be  unaware  of  any  urinary  trouble. 

Diagnosis. — This  is  based  upon  pus  in  the  urine,  pain,  tenderness  and  at 
times  tumor  in  the  region  of  the  kidney,  the  fever  and  the  development  of  an 
otherwise  inexplicable  gastro-intestinal  catarrh.  In  the  absence  of  pyonephrosis, 
there  are  usually  polyuria  and  constant  pyuria.  Oliguria  is  an  ominous  sign. 
The  urine  is  alkaline.  Microscopic  examination  shows  hyaline  casts  and  some- 
times fragments  of  renal  tissue.  Exceptionally  there  is  slight  hsematuria, 
rarely  the  bleeding  is  free;  it  is  usually  due  to  calculus.  There  may  be  absence 
of  both  spontaneous  and  provoked  pain.  There  is  frequent,  often  painful, 
urination,  especially  during  acute  exacerbations  of  the  chronic  inflammation. 
When  pyelonephritis  is  complicated  by  pyonephrosis  there  is  also  the  develop- 
ment of  a  swelling  which  may  exhibit  variations  in  size;  if  but  one  kidney  is 
affected  there  may  be  intermittent  polyuria  and  pyuria. 

The  differential  diagnosis  of  chronic  pyelonephritis  from  cystitis  may  be 
difficult.  Cystitis,  however,  does  not  produce  the  constitutional  symptoms,  and 
ureter  catheterization  will  show  the  absence  of  pus  from  the  urine  as  it  escapes 
from  the  kidneys.  Cystitis  and  pyelonephritis  are  often  associated.  In  such 
cases  ureteral  catheterization,  by  showing  that  pus  comes  from  the  kidney,  is 
again  serviceable;  moreover,  fever,  rapid  deterioration  in  health,  and  pronounced 
gastro-intestinal  symptoms  are  characteristic  of  the  kidney  affection. 

Tuberculous  pyelonephritis,  usually  a  mixed  infection  when  renal  symptoms 
become  marked,  may  be  characterized  by  the  presence  of  tuberculous  infection 
in  other  portions  of  the  genito-urinary  tract,  the  finding  of  the  Koch  bacillus, 
and  the  tuberculin  test. 

It  is  important  to  find  out  whether  both  kidneys  are  affected.  This  will 
be  determined  by  the  results  of  palpation  and  tests  of  renal  function. 

Treatment. — The  preventive  treatment  of  pyelonephritis  is  particularly 
important.  In  view  of  the  fatality  of  this  affection,  it  is  impossible  to  express 
too  emphatically  the  necessity  for  asepsis  even  in  so  trivial  an  operation  as 
catheterization,  especially  when,  as  after  chronic  retention,  the  urinary  tract  is 
predisposed  to  infection. 

When  pyelonephritis  has  developed  it  should  be  treated  as  a  combination 


RENAL  INFECTIONS  643 

of  uraemia  and  septicaemia.  Liquid  diet,  particularly  milk,  the  administration 
of  diuretics  and  of  diluents,  counter-irritation  over  the  kidneys, — in  acute  cases 
by  dry  cups  followed  by  hot  fomentations, — and  the  administration  of  laxatives, 
are  indicated  as  the  means  of  combating  uraemia.  Since  septicaemia  causes 
death  by  exhaustion,  the  administration  of  alcohol  well  diluted  and  of  as  much 
nourishment  as  can  be  assimilated  is  desirable.  Quinine  should  be  avoided,  since 
it  is  useless  in  small  doses,  and  in  full  doses  markedly  congests  the  kidneys. 
Small  doses  of  salol  are  serviceable,  since  they  tend  to  prevent  ammoniacal 
fermentation  in  the  kidney  pelvis. 

When  pyonephrosis  develops  in  the  course  of  pyelonephritis,  or,  even  in 
the  absence  of  this,  if  symptoms  are  progressive,  nephrotomy  or  nephrostomy 
with  free  drainage  is  indicated.  The  kidney  should  be  opened  into  the  pelvis 
on  its  convex  border,  and  the  examining  finger  should  discover  and  break  into 
every  pus-collection  of  appreciable  size.  Theoretically  nephrectomy  is  indicated, 
since  the  kidney  is  often  riddled  with  multiple  abscesses;  the  infection  is,  how- 
ever, frequently  bilateral.  When  after  drainage  the  symptoms  do  not  improve 
and  there  is  a  free  discharge  of  pus  through  the  lumbar  wound,  a  secondary 
nephrectomy  may  be  performed  if  examinations  have  shown  that  the  other 
kidney  is  normal.  The  degenerated  fatty  capsule  in  chronic  inflammations  is 
often  adherent  to  the  kidney  capsule  proper,  and  to  surrounding  organs  and 
structures,  rendering  enucleation  of  the  kidney  a  difficult  and  dangerous  pro- 
cedure.   Subcapsular  nephrectomy  should  then  be  done. 

Suppurative  Nephritis,  Acute  H^ematogenous  Suppurative  Nephri- 
tis.— Under  this  heading  are  classified  renal  suppurations  in  which  the  agents 
of  infection  enter  the  kidneys  through  its  vessels,  through  its  lymph-channels, 
or  by  contiguity.  Such  suppurations  are  seen  in  pyaemia,  in  endocarditis,  and 
in  the  acute  infectious  fevers,  as  the  result  of  extension  of  infection  from 
adjacent  tissues,  or  in  consequence  of  traumatism  or  exposure  to  cold. 

In  haematogenous  infections  the  condition  is  often  unilateral,  though  em- 
bolic infection  may  simultaneously  involve  both  kidneys.  The  abscesses  are 
generally  multiple;  single  large  abscesses  are  occasionally  seen.  Haematogenous 
abscesses  first  form  in  the  cortex ;  from  these  the  entire  gland  generally  becomes 
infected  (Fig.  345).  The  abscesses  may  coalesce,  and  in  some  cases  renal 
disintegration  goes  so  far  that  nothing  remains  but  a  sac  (the  capsule)  filled 
with  pus.  In  non-haematogenous  suppuration  the  process  may  commence  in 
any  part  of  the  kidney,  according  to  the  origin  of  infection.  The  abscesses  may 
rupture  into  the  pelvis  or  through  the  capsule,  with  the  production  of  peri- 
nephric suppuration.  It  is  in  suppurative  nephritis  that  metastasis  most  often 
occurs. 

When  the  kidney  infection  is  simply  an  expression  of  a  general  pyaemia  the 
suppuration  is  rarely  extensive;  small  abscesses  form  about  the  glomeruli  and 
the  smaller  vessels  of  the  cortex  of  both  kidneys,  often  with  blocking  of  the 
uriniferous  tubes.  The  renal  substance  is  the  seat  of  a  parenchymatous  inflam- 
mation.   In  rare  cases  of  long  duration,  amyloid  degeneration  may  occur. 

Symptoms. — Acute  haematogenous  renal  infection  is  often  inaugurated  by 
chill  and  high  fever;  sometimes  patients  complain  of  violent  pains  in  the  loin. 
This  may  be  associated  with  tympany,  tenderness  and  vomiting.     Tenderness 


544  GENITO-URINARY  SURGERY 

is  most  marked  at  the  costovertebral  angle,  and  may  be  the  only  localizing 
symptom.  Not  infrequently  a  marked  oliguria  (or  even  anuria)  occurs.  Blood 
and  hyaline  casts  may  be  present  in  the  urine. 

Fever  of  a  hectic  type  develops  in  nearly  all  cases,  and  chills  occur  irregu- 
larly. Violent  attacks  of  hiccough  and  vomiting  are  sometimes  noted;  these 
are  probably  uraemic.  There  are  generally  lumbar  pains,  severe  prostration,  and 
the  rapid  development  of  a  typhoid  state,  the  sensorium  becoming  clouded. 


Fig.  345. — Acute  haematogenous  suppurative  nephritis.  A,  exter- 
nal appearance;  B,  view  of  mesial  section.  Note  the  cortical  arrangement  of 
the  miliary  abscesses.  (No.  3861.  Laboratory  of  Surgical  Pathology,  Uni- 
versity of  Pennsylvania.) 

and  the  patient  lying  with  symptoms  of  both  pyaemia  and  uraemia.     T3^ical 
uraemia  with  convulsions  has  been  noted  in  a  few  cases. 

The  urinary  changes  are  not  constant.  In  some  cases  there  are  no  alterations 
other  than  oliguria.  A  little  blood  and  a  few  hyaline  casts  are  often  found  on 
microscopic  examination.  Later  in  the  disease  granular  casts  give  evidence  of 
parenchymatous  degeneration.  Pyuria,  especially  if  profuse,  indicates  that  an 
abscess  has  been  evacuated  into  the  pelvis;  this  may  be  followed  by  marked 
amelioration  in  the  general  condition.  In  rare  cases  pieces  of  renal  tissue  may 
be  voided. 


RENAL  INFECTIONS  645 

Diagnosis. — Since  enlargement  of  the  kidney  is  usually  slight,  suppurative 
nephritis  will  not  ordinarily  be  confused  with  extrarenal  suppuration.  The 
course  of  suppurative  nephritis  is  too  acute  for  neoplasms;  hydronephrosis, 
pyonephrosis,  and  perinephric  abscess  generally  occasion  much  more  marked 
enlargement.  Tympany,  tenderness,  and  pain  in  the  right  lumbar  region  so 
often  simulate  acute  appendicitis  that  an  early  differential  diagnosis  may  be 
most  difficult.  The  careful  examination  of  the  urine,  the  history  and  clinical 
course  of  the  case,  and  exploration  of  the  lower  urinary  tract  will  usually  lead 
to  the  diagnosis.  Renal  suppuration,  unless  well  drained,  causes  a  circulatory 
leucocytosis. 

Treatment. — This  is  at  first  expectant  and  symptomatic.  The  patient  is 
kept  absolutely  at  rest,  and  careful  attention  is  paid  to  the  constitutional  con- 
dition. If  the  constitutional  symptoms  are  those  of  profound  and  increasing 
sepsis,  and  the  local  symptoms  are  unilateral,  an  early  nephrectomy  may  be 
performed.  Partial  nephrectomy  has  been  performed  successfully,  but  is  more 
hazardous  than  the  removal  of  the  entire  organ.  It  is  often  the  case  that 
symptoms  pointing  to  the  renal  location  of  the  infection  are  masked  until  the 
condition  of  the  patient  will  not  admit  of  an  operation.  Nephrotomy  may  be 
done  in  an  effort  to  save  an  otherwise  hopeless  case.  When  suppurative  nephri- 
tis develops  in  pyaemia  it  is  a  local  expression  of  the  general  condition,  to  which 
treatment  is  mainly  directed. 

Perinephritis. — Perinephritis  is,  strictly  speaking,  an  inflammation  of  the 
fibrous  capsule;  the  term,  as  commonly  used,  implies  inflammation  of  the  fatty 
capsule.  Inflammation  of  the  true  capsule  occurs  in  nearly  all  renal  diseases. 
It  is  frequently  sclerotic,  thickened,  and  adherent  to  the  gland;  it  may  sup- 
purate secondarily  to  adjacent  renal  suppuration,  or  it  may  become  involved 
in  tuberculous  and  malignant  processes, 

Beyond  the  evidences  of  the  renal  or  perirenal  disease  which  causes  it, 
perinephritis  presents  no  symptom  except  pain.  It  seems  clearly  established 
that  inflammation  of  the  true  kidney  capsule  causes  more  pain  than  involve- 
ment of  the  secreting  portion  of  the  kidney. 

Inflammation  of  the  fatty  capsule  of  the  kidney  is  common,  since  this  tissue 
possesses  a  low  degree  of  power  of  resistance  to  infection.  It  is  not  necessarily 
suppurative.  After  a  long-lasting  nephritis  it  sometimes  happens  that  the  capsule 
of  the  kidney  is  converted  into  a  dense  fibrous  investment,  the  fat  having  almost 
entirely  disappeared,  or  the  fatty  envelope  of  the  organ  may  be  greatly  thick- 
ened, showing  an  increase  of  both  adipose  and  fibrous  tissue.  This  overgrowth 
is  particularly  abundant  about  the  hilum,  and  much  resembles  in  structure 
lipomata  occurring  in  other  portions  of  the  body. 

There  are  two  forms  of  perinephric  abscess:  the  primary,  in  which  the 
suppuration  arises  de  novo  in  the  fatty  capsule;  and  the  secondary,  in  which 
the  primary  focus  lies  elsewhere. 

The  primary  forms  of  perinephric  abscess  may  arise  in  several  ways.  Trau- 
matism is  responsible  for  some  cases.  In  injuries  to  the  lumbar  region  when 
there  is  penetration,  laceration,  or  cutaneous  abrasion,  pyogenic  microorganisms 
have  direct  access  to  the  tissues,  and  infection  may  follow;  but  there  have 
been  cases  of  perinephric  suppuration  following  traumatism  in  which  no  super- 


646  GENITO-URINARY  SURGERY 

ficial  injuries  occurred.  The  rare  instances  in  which  such  suppuration  has 
followed  severe  jarring  to  the  trunk  or  heavy  lifting  must  be  classed  with  the 
primary  cases.  Many  cases  have  been  attributed  to  colds.  The  infection  may 
be  explained  in  one  of  several  ways:  it  may  have  been  haematogenous,  the 
traumatism  or  the  cold  having  rendered  the  tissues  susceptible  to  the  circulatory 
microorganisms;  or  the  traumatism  may  have  excited  to  activity  a  latent  dis- 
ease.   There  may  also  be  a  perinephritis  due  to  actinomycosis. 

The  secondary  perinephric  suppurations  arise  from  many  causes.  From 
the  kidney  secondary  infection  is  common.  In  any  case  of  suppurative  nephritis, 
pyelonephritis,  pyonephrosis,  pyelitis  (especially  associated  with  calculus), 
ureteritis,  or  tuberculous  disease,  a  perinephric  abscess  may  form.  The  infec- 
tion may  be  due  either  to  the  rupture  of  an  area  of  renal  suppuration  into  the 
perinephric  tissue,- or  to  extension  through  the  true  capsule  without  discoverable 
opening.  The  infection  may  reach  the  fatty  capsule  from  its  periphery.  Thus, 
appendicitis,  parametritis  and  parovaritis,  abscess  of  the  spleen,  gall-bladder, 
or  liver,  subphrenic  abscess,  psoas  abscess,  or  any  bone  suppuration,  and  in 
rare  cases  abscess  of  the  lung  or  pleura,  may  be  the  primary  focus  of  suppuration. 

In  other  cases  infection  may  reach  the  fatty  tissues  by  the  blood-  or 
lymph-channels.  In  pyaemia  or  internal  suppuration,  in  puerperal  fever,  or  after 
operations  on  the  prostate,  bladder,  testicles,  rectum,  or  ischiorectal  spaces, 
such  an  infection  may  occur.  Finally,  there  are  rare  instances  of  perinephric 
suppuration  entirely  without  obvious  cause,  in  which  an  infection  by  micro- 
organisms from  the  colon  may  be  possible.  The  condition  is  most  common  in 
middle-aged  men,  but  has  been  noted  in  infants  and  in  the  aged.  It  is  usually 
right-sided,  exceptionally  it  is  bilateral.  The  abscesses  may  be  large  or  small, 
single  or  multiple.  The  latter  condition  is  most  often  seen  in  cases  where 
infection  has  proceeded  from  the  kidney.  The  pus  may  spread  from  the  fatty 
capsule  and  infiltrate  the  loose  retroperitoneal  tissue ;  in  other  cases  it  is  walled 
in  by  a  strong  fibrous  capsule.  The  perinephric  lipomatous  investment  is  more 
or  less  necrotic,  and  bleeding  is  not  uncommon  in  the  infected  area.  The  pus  is 
usually  bland  and  odorless;  it  may,  however,  be  fetid,  or  urinous.  According  to 
its  origin  the  pus  may  contain  renal  tissue,  concretions,  parasites,  or  shreds  of 
neoplasm.  The  kidney-substance  often  becomes  secondarily  involved,  and  amy- 
loid degeneration  may  ensue.    Metastasis  to  distant  organs  is  rare. 

The  main  portion  of  the  abscess  is  usually  placed  directly  behind  the 
kidney,  but  the  pus  may  burrow  in  various  directions,  and  this  tendency  is  of 
clinical  importance.  It  may  descend  into  the  pelvis  behind  the  peritoneum, 
opening  into  the  rectum,  vagina,  urethra,  or  bladder  (in  about  four  per  cent, 
of  recorded  cases).  It  may  pass  down  within  the  sheath  of  the  psoas  muscle 
and  point  below  Poupart's  ligament,  may  follow  the  iliac  vessels  and  point  in 
the  femoral  region,  or  may  pass  out  through  the  sacro-sciatic  foramen  and 
point  in  the  gluteal  region.  Rupture  into  the  ureter  or  the  kidney  is  possible. 
In  a  few  cases  the  abscess  has  discharged  into  the  colon  (of  six  cases,  four 
recovered),  duodenum,  or  stomach;  the  liver  may  be  secondarily  infected.  Rup- 
ture into  the  peritoneal  cavity  is  rare,  as  the  peritoneum  becomes  thick  and 
fibrous  as  a  result  of  inflammation.  The  upward  pressure  of  an  extensive 
perinephric  abscess  may  be  sufficient  to  cause  distressing  dyspnoea. 


RENAL  INFECTIONS  647 

Perhaps  the  most  frequent  direction  of  pointing,  with  the  exception  of  those 
abscesses  which  open  in  the  lumbar  region,  is  towards  the  pleural  cavity.  Senator 
long  ago  called  attention  to  the  existence  of  a  serous  pleurisy  which  often  com- 
plicates perinephritis,  even  though  the  abscess  has  not  directly  involved  the 
pleura.  There  is  a  triangular  defect  in  the  diaphragm  just  behind  the  upper 
portion  of  the  kidney  through  which  infection  readily  passes.  After  rupture 
through  the  diaphragm  the  pus  may  infiltrate  the  retropleural  tissue,  penetrate 
the  pleural  cavity,  causing  empyema,  or  rupture  into  the  lung,  giving  rise  to 
pulmonary  abscess.  In  some  cases  profuse  purulent  expectoration  or  the  symp- 
toms of  suppurative  pleuritis  first  attract  attention  to  the  perinephric  suppura- 
tion, though,  unless  it  is  remembered  that  perinephritis  may  be  a  causative 
factor,  the  etiology  of  the  pulmonary  abscess  or  the  empyema  may  remain  unsus- 
pected. In  Fisher's  series  of  ninety-four  cases  the  pleura  was  affected  in  twenty- 
four  per  cent.,  the  lungs  in  twenty  per  cent.,  and  the  pericardium  in  six  per  cent. 

Symptoms. — The  cardinal  symptoms  of  perinephritis  are  tumor,  pain,  ten- 
derness, and  fever.  The  local  symptoms  depend  upon  the  formation  of  pus  and 
the  direction  of  its  extension.  In  the  cases  which  are  secondary  to  inflammation 
of  the  appendix,  the  uterus  or  its  adnexa,  the  gall-bladder,  etc.,  the  symptoms 
of  perinephritis  are  masked  by  those  of  the  original  disease.  This  is  also  true  of 
suppuration  secondary  to  infection  of  the  urogenital  tract  or  which  occurs  in 
the  course  of  a  general  pyaemia. 

The  symptoms  are  clearly  marked  in  cases  following  traumatism  or  cold  or 
in  those  of  haematogenous  origin  unassociated  with  general  pyaemia.  Pain,  chill, 
and  fever  are  generally  the  early  phenomena. 

The  pain  is  at  first  confined  to  the  loin  and  aggravated  by  pressure;  soon 
any  motion  of  the  trunk  or  leg  of  the  affected  side  greatly  increases  it.  The 
patient  lies  on  his  back,  with  a  lateral  curvature  the  concavity  of  which  is 
towards  the  side  involved;  the  thigh  is  adducted  and  flexed.  At  times  severe 
pains  may  radiate  into  the  genitalia,  around  the  abdomen,  or  into  the  thigh; 
this  is  due  to  pressure  upon  the  nerve  trunks.  Even  in  the  feverless  walking 
cases  the  muscles  attempt  to  protect  the  inflamed  region;  the  thigh  is  adducted, 
the  body  is  bent  forward,  and  the  trunk  is  fixed,  usually  with  a  lumbar  flexion 
towards  the  inflammatory  focus;  the  patient  limps.  In  a  few  cases  partial 
anaesthesia  and  paresis  have  been  noted.  Since  the  third  and  fourth  lumbar 
nerves  supply  the  muscles  which  flex  the  thigh,  this  symptom  of  flexion  is  most 
prominent  where  the  abscess  lies  directly  over  them, — that  is,  about  the  lower 
third  of  the  kidney.  In  some  cases  the  thigh  is  fixed  in  flexion;  in  other  cases 
any  m.otion  except  extension  may  be  performed  painlessly. 

The  fever  may  be  high  or  moderate;  it  is  usually  markedly  intermittent  or 
even  remittent,  and  often  presents  the  distinct  hectic  type.  Chills  and  profuse 
perspiration  are  common.  The  blood  generally  shows  leucocytosis,  except  when 
the  condition  is  tuberculous.  The  gastro-intestinal  tract  is  deranged,  there  are 
anorexia,  vomiting,  sometimes  tympany,  and  these  disturbances  may  be  much 
aggravated  by  the  pressure  of  the  abscess  upon  the  colon,  with  the  production 
of  obstruction  and  consequent  stercoraemia. 

The  local  symptoms  develop  early.  There  is  a  tender  tumor  in  the  loin, 
which  may  be  indistinctly  fluctuating  and  irregular  in  outline.    The  abscess  lies 


648  GENITO-URINARY  SURGERY 

under  the  colon,  and  therefore  usually  does  not  produce  an  area  of  dulness  od 
anterior  percussion,  but  flatness  is  marked  in  the  lumbar  region. 

The  loin  is  usually  swollen;  this  swelling  may  be  slight  or  so  distinct  that 
the  lumbar  region  protrudes.  This  tumor  does  not  move  with  respiration. 
When  external  pointing  is  about  to  take  place,  the  skin  over  the  loin  becomes 
red  and  waxy,  and  distinct  oedema  develops;  the  abscess  usually  opens  in  or 
near  Petit's  triangle. 

Supradiaphragmatic  symptoms  often  develop.  Independent  of  perforation 
into  the  pleura,  severe  pleurisy  may  occur,  presenting  the  recognized  symptoms 
of  that  condition.  In  nearly  all  cases  there  is  restricted  abdominal  breathing, 
and  hence  some  dyspnoea.  Apart  from  diaphragmatic  rigidity,  extreme  dyspnoea 
may  be  produced  by  direct  pressure  of  a  large  abscess. 

In  the  acute  cases  the  general  strength  of  the  patient  is  quickly  and  markedly 
reduced,  prostration  is  extreme,  and,  unless  there  is  natural  or  artificial  evacua- 
tion, the  patient  becomes  profoundly  septic,  or  even  may  succumb  to  a  general 
pysemia.  The  tuberculous  cases,  however,  and  some  of  the  infective  cases,  run 
a  mild  chronic  course,  in  which  the  local  phenomena  largely  predominate. 

When  the  abscess  forms  visceral  adhesions,  or  shows  a  tendency  towards 
pointing  externally,  additional  symptoms  usually  appear,  though  evacuation 
may  be  accomplished  almost  without  symptoms.  Opening  into  the  loin  is 
heralded  by  the  well-known  local  signs  of  abscess-formation.  Evacuation 
into  the  intestines  is  preceded  and  accompanied  by  colicky  or  continuous  pains 
and  a  desire  to  defecate;  when  such  symptorns  arise,  pus  should  be  sought  for 
in  the  evacuation.  Symptoms  of  acute  peritonitis  may  appear;  these  are  usually 
reflex,  or  indicate  intestinal  implication  rather  than  peritonitis.  Rupture  into 
the  kidney  or  the  ureter  is  accompanied  by  mild  or  severe  renal  colic,  with 
frequent  urination;  the  same  pains,  together  with  vesical  irritability,  may  be 
present  in  case  of  rupture  into  the  bladder,  though  this  may  take  place  without 
producing  any  symptoms.  The  downward  and  forward  extension  of  the  abscess 
is  indicated  by  the  increasing  area  of  tenderness  and  the  detection  by  palpation 
of  inflammatory  thickening  of  the  tissues. 

Rupture  into  the  pleura  is  accompanied  by  severe  cough,  dyspnoea,  and  the 
physical  signs  of  empyema;  later  there  forms  a  lung  abscess,  or  a  pneumo- 
pyothorax ;  such  an  abscess  may  be  evacuated  through  a  bronchus. 

In  most  cases  immediately  following  rupture  of  the  abscess  there  is  marked 
amelioration  of  general  symptoms,  and  the  size  of  the  tumor  is  decreased,  but 
this  may  not  be  demonstrable.  When  fistulse  have  formed  they  will  discharge 
regularly  and  almost  continuously,  but  not  infrequently  the  tracts  become 
blocked;  this  is  followed  by  prompt  exaggeration  of  both  the  general  symptoms, 
and  the  local  signs. 

Diagnosis. — Both  noninflammatory  and  inflammatory  conditions  may  be 
confounded  with  perinephritic  abscess  in  its  early  stages.  Among  the  former  are 
lumbago  and  renal  colic.  In  neither  of  these  is  there  fever  nor  tumor.  In 
lumbago  pressure  is  distinctly  comforting,  and  there  is  never  radiation  of  pain 
to  the  genitalia;  frequently  the  condition  is  bilateral.  Pain  similar, to  that  of 
"enal  colic  is  exceptional  before  the  abscess  has  reached  sufficient  size  to  give 
unmistakable  signs  of  its  true  character  by  tumor  formation  and  tenderness. 


RENAL  INFECTIONS  649 

Of  inflammatory  conditions  of  other  tissues  which  may  be  confounded  with 
perinephritis,  appendicitis,  parametritis,  and  parovaritis  are  the  most  common^ 
with  abscess  of  the  gall-bladder,  Uver,  or  spleen  as  rare  causes  of  confusion. 

The  pain  in  appendicitis  generally  begins  as  an  intestinal  colic,  and  later 
radiates  through  the  abdomen  or  towards  the  umbilicus  rather  than  into  the 
genitalia  or  down  the  thigh.  The  dulness  in  subacute  and  neglected  cases  is 
often  in  front  of  the  colon,  and  more  marked  anteriorly  than  posteriorly,  and 
thfe  peritoneal  symptoms  are  more  pronounced.  Moreover,  the  point  of  greatest 
tenderness  does  not  coincide  in  the  two  affections.  '  These  elements  of  difference, 
with  the  history,  will  usually  determine  the  diagnosis.  Rectal  exploration  should 
also  be  made,  and  the  urine  should  be  carefully  examined  for  pus. 

Parametritis  and  parovaritis  can  generally  be  differentiated  by  the  history 
and  by  vaginal  and  rectal  examinations. 

Visceral  abscesses  must  be  excluded  by  the  history  and  by  physical  examina- 
tion. 

Coxitis  and  spinal  tuberculosis  may  be  closely  simulated  by  perinephric 
abscess.  The  position  of  the  leg  may  be  the  same  as  in  coxitis,  but  the  other 
joint-symptoms  are  not  present.  Spinal  tuberculosis  causes  a  marked  rigidity 
of  the  vertebral  column,  with  tenderness  over  certain  points,  pain  on  concussion, 
with  relief  of  pain  on  extension  of  the  spine,  and  angular  deformity;  these 
symptoms  are  absent  in  perinephric  abscess.  Moreover,  there  is  no  leucocytosis 
in  bone  tuberculosis  unassociated  with  mixed  infection. 

Neoplasms  of  the  kidney  or  a'djacent  tissues  are  sometimes  very  difficult  to 
exclude,  since  the  swelling  of  a  perinephric  abscess  does  not  always  fluctuate. 
The  age  of  the  patient  might  suggest  the  probability  of  renal  neoplasm;  fever 
and  flexion  of  the  leg  would  almost  positively  point  to  abscess.  The  examina,tion 
of  the  urine  sometimes  furnishes  evidence  of  perinephritis,  though,  unless  the 
secreting  substance  or  the  pelvis  of  the  kidney  be  inflamed,  the  examination 
will  be  negative.  Rapidly  growing  sarcomata  often  cause  a  decided  leucocytosis, 
while  a  mild  leucocytosis  may  be  present  in  cases  of  cancer;  thus  this  sign  of 
abscess  may  be  misleading.  In  doubtful  cases  an  exploratory  puncture  is 
justifiable,  since  a  diagnosis  can  usually  be  made  from  the  material  aspirated. 

Ovarian  cysts  can  usually  be  excluded  by  vaginal  and  rectal  exam.ination 
and  by  the  history. 

Of  the  inflammatory  conditions  of  the  kidney  which  may  be  mistaken  for 
perinephric  abscess,  pyonephrosis,  pyelitis,  and  suppurative  nephritis  are  the 
most  frequent.  The  differential  diagnosis  is  often  very  difficult,  but,  as  the 
treatment  of  all  is  nearly  the  same,  the  difficulties  are  not  embarrassing.  The 
tumor  of  hydronephrosis  or  pyonephrosis  resulting  from  a  blocking  of  the  ureter 
is  of  more  sudden  formation  than  an  abscess;  there  is  not  the  marked  flexion 
of  the  thigh,  the  pain  is  more  paroxysmal,  and  there  is  in  hydronephrosis  no 
fever.  Pyelitis  and  suppurative  nephritis  do  not  occasion  swelling,  severe  pain^ 
or  flexion  of  the  thigh. 

The  knowledge  of  leucocytosis  in  the  various  renal  inflammations  has  not 
yet  been  so  formulated  as  to  be  of  clinical  service.  Careful  repeated  examina- 
tions of  the  urine  and  the  history  of  the  case  are  the  most  important  elements  in 
differentiating  perinephric  abscesses  from  the  renal  infections. 


550  GENITO-URINARY  SURGERY 

Prognosis. — This  is  dependent  upon  the  cause  of  the  perinephritis.  When 
the  perinephric  inflammation  is  secondary  to  infection  of  the  kidney  the  prog- 
nosis must  be  guarded.  When  it  follows  contusion  of  the  kidney  the  prognosis 
is  extremely  favorable  if  the  condition  is  recognized  and  promptly  treated. 

The  course  of  primary  perinephritis  is  usually  acute,  the  symptoms  are  severe, 
and  the  inflammation  quickly  terminates  in  death  or  evacuation  of  the  abscess. 
In  a  few  cases  the  abscess  has  become  encysted,  with  complete  recovery. 

In  case  of  pointing  the  subsequent  history  of  the  case  depends  upon  the 
site  of  evacuation.  Most  favorable,  of  course,  is  lumbar  or  iliac  evacuation, 
next  is  rupture  into  the  colon,  then  rupture  into  the  urinary  tract,  while  the 
most  unfavorable  is  rupture  through  the  diaphragm.  In  the  secondary  cases 
the  duration  and  prognosis  are  obviously  influenced  by  the  primary  conditions. 

Treatment. — When  the  diagnosis  of  perinephric  abscess  is  fairly  established 
there  can  be  no  reason  for  delay  in  surgical  inter\'ention.  Palliative  treatment 
is  indicated  only  during  the  time  the  surgeon  is  determining  whether  or  not  pus 
is  present  in  the  perinephric  region.  Before  the  formation  of  a  distinct  tumor 
it  may  be  quite  impossible  to  distinguish  perinephritis  from  any  of  the  forms 
of  kidney  infection.  During  this  period  the  treatment  appropriate  to  suppurative 
renal  disease  is  indicated. 

When  incision  is  practised,  the  opening  should  be  in  the  lumbar  region,  and 
should  be  sufficiently  large  to  allow  of  exploration  of  the  kidney  and  its  pelvis. 
It  is  best  to  use  the  finger  instead  of  the  knife  to  open  up  the  abscess-cavity 
and  break  down  septa.  An  admixture  of  urine  with  the  pus  indicates  that  there 
is  an  opening  into  the  kidney  pelvis,  and  suggests  exploration  of  this  cavity  and 
of  the  ureter  for  the  purpose  of  removing  calculi  or  relieving  obstruction. 
Frequently  the  pus  has  a  faecal  odor,  suggesting  a  communication  with  the 
bowel.  This  odor  does  not,  however,  indicate  the  formation  of  an  intestinal 
fistula,  but  is  due  to  the  infecting  organisms.  When  the  abscess  has  burrowed 
widely  its  accessory  cavities  should  be  opened  and  drained;  healing  of  these 
may  be  confidently  expected  after  drainage  of  the  centre  of  infection.  In  cases 
of  long  duration  and  where  the  abscess  is  of  large  size,  the  pressure  may  have 
caused  marked  atrophy  of  the  kidney,  or  this  organ  may  be  so  extensively 
infiltrated  with  pus  that  nephrectomy  is  indicated.  In  such  cases  it  is  safest  to 
perform  two  operations,  letting  the  patient  recover  from  the  constitutional 
effects  of  suppuration  before  submitting  him  to  the  shock  and  strain  of  a 
nephrectomy. 

When  the  abscess  has  already  opened,  into  a  bronchus  or  the  colon,  for 
instance,  it  is  possible  that  spontaneous  cure  may  result.  Surgical  intervention 
may  then  be  delayed,  provided  the  patient's  general  condition  is  satisfactory 
and  the  quantity  of  pus  discharged  is  diminishing.  Should  hectic  temperature, 
emaciation,  and  loss  of  strength  show  deficient  drainage,  the  centre  of  infection 
should  be  '  drained  directly.  The  after-treatment  of  the  incision  made  for 
drainage  is  important,  since  fistulse  are  liable  to  persist,  especially  in  cases  of 
long-standing  suppuration  and  in  those  complicated  by  pyelonephritis.  Drainage 
should  be  thorough. 

Actinomycosis. — Israel  was  the  first  to  describe  actinomycosis  of  the  human 
kidney.     Although  the  disease  is  very  rare,  he  saw  it  both  as  a  primary  and 


RENAL  INFECTIONS  651 

a  secondary  infection;  the  latter  is  the  more  common.  Those  following  agricul- 
tural pursuits  and  leather  industries  are  the  ones  afflicted  with  the  actinomycosis. 
The  diagnosis  of  involvement  of  the  kidney,  secondary  to  actinomycosis  ot  the 
lung,  pleura,  etc.,  is  largely  inferential  after  the  appearance  of  renal  symptoms, 
and  is  not  difficult.  I  he  symptoms  of  primary  renal  actinomycosis,  according 
to  Israel,  are  fever,  pain  and  tenderne::s  in  the  affected  region,  cough  which 
may  disappear,  resistance  in  the  hypochondriac  region  or  a  doubtfully  palpable 
kidney,  oedema  of  the  lumbar  region,  and  slight  leucocytosis.  The  urine  is 
normal.  The  fever  is  a  combination  of  the  remittent  and  intermittent  types. 
The  closest  approximation  to  the  correct  diagnosis  will  likely  be  suppurative 
perinephritis.  The  precise  diagnosis  will  in  all  probability  be  deferred  until 
operation,  when  the  discovery  of  pus  containing  the  characteristic  sulphur-like 
granules  will  furnish  the  clue  and  the  microscope  will  demonstrate  the  ray- 
fungus. 

The  disease  locates  itself  primarily  in  the  cortex  of  the  kidney,  thus  giving 
rise  to  an  associated  perinephritis. 

Nephrectomy  has  resulted  in  cure,  though  with  subsequent  prolonged  sinus 
formation.  Active  immunization  with  the  ray-fungus  should  be  employed 
after  nephrectomy. 

Pyelo-Paranephric  Cyst. — A  cystic  tumor  within  the  paranephric  tissue 
connecting  with  a  fistula  of  the  renal  pelvis  has  been  described  by  Gallaudet. 
It  may  be  due  to  a  simultaneous  rupture  of  the  renal  pelvis  and  the  formation 
of  a  paranephric  hsematoma.  The  blood  finally  becoming  absorbed  leaves  a 
connective-tissue  capsule  formed  by  perinephric  tissue,  the  cavity  of  which 
communicates  with  the  pelvis  of  the  kidney.  It  may  occur  as  the  result  of  trau- 
matism or  of  ulceration  of  the  renal  pelvis  with  urinary  extravasation.  Removal 
of  the  mass  and  closure  of  the  fistula  would  constitute  the  treatment. 

Renal  Infarct. — The  first  indication  of  this  in  a  patient  with  valvular 
cardiac  disease  may  be  sudden  vomiting.  There  may  be  either  retention, 
suppression  or  incontinence  of  urine,  later  followed  by  polyuria.  Haematuria 
is  rare,  albuminuria  develops  rapidly,  but  is  transient.  The  renal  pain  and 
tenderness  are  increased  by  lying  on  the  sound  side  and  the  sensibility  of  the 
ilio-hypogastric  nerve  is  exaggerated  (Schmidt). 

Phlebitis  or  the  Renal  and  Perirenal  Veins  is  a  rare  condition,  which 
may  arise  as  a  result  of  pyaemia,  or  may  be  a  beginning  of  nephric  or  perinephric 
abscess.  It  presents  the  symptoms,  both  constitutional  and  local,  of  severe 
acute  inflammation  in  or  about  the  kidney  with  extreme  tenderness,  rigidity, 
pain,  oedema  of  the  surrounding  soft  parts,  chills,  fever  and  sweats  of  a  hectic 
type  going  on  to  the  production  of  pronounced  cachexia.  The  urinary  symp- 
toms may  be  negative,  or,  if  abscesses  have  been  formed,  there  may  be  pus 
and  blood  in  the  urine.  Suppression  may  occur.  The  extreme  rigidity  and 
tenderness  which  call  attention  to  the  kidney  may  preclude  palpation  of  the 
organ.  The  diagnosis  is  made  largely  by  exclusion  and  upon  exploration  of  the 
kidney.    The  few  cases  seen  have  been  unilateral. 


CHAPTER  XXIX 

RENAL  TUBERCULOSIS  AND  FISTULA 

Tuberculosis  of  the  kidne}^  may  be  one  of  the  many  lesions  of  a  general 
miliary  tuberculosis,  or  it  may  be  a  localized  process,  perhaps  the  single  dis- 
coverable tuberculous  lesion. 

GENERAL  TUBERCULOSIS  AFFECTING  THE  KIDNEY 
Renal  lesions,  as  a  part  of  a  general  miliary  tuberculosis,  are  fairly  common 
in  the  young.  The  multiple  miliary  deposits  do  not  attain  large  dimensions, 
nor  do  they  undergo  the  marked  retrograde  changes  which  are  seen  in  the  more 
chronic  forms  of  the  disease.  Urinary  symptoms  are  usually  masked  by  those 
of  the  general  infection,  to  the  control  of  which  treatment  is  to  be  directed. 

LOCALIZED  RENAL  TUBERCULOSIS 

This  may  be  acute  or  chronic,  primary  or  secondary.  The  chronic  secondary 
forms  are  those  most  commonly  encountered,  the  acute  stage  having  escaped 
notice. 

In  the  primary  infections  the  route  is  probably  hsematogenous.  In  the  sec- 
ondary infections  the  primary  focus  may  be  in  any  part  of  the  body;  in 
comparison  to  the  total  number  of  cases  of  tuberculosis  the  kidneys  are  not 
frequently  involved.  Infection  carried  by  the  blood  to  the  kidney  is  the 
usual  beginning  of  urogenital  tuberculosis,  which  later  involves  the  lower 
tract. 

Taking  all  cases  together,  males  are  probably  more  frequently  affected  than 
are  females,  the  proportion  being  about  2  to  L  Renal  tuberculosis  occurs 
most  commonly  between  the  ages  of  twenty  and  forty-five,  though  it  is  by 
no  means  conlined  to  these  limits;  the  extremes  are  three  months  and  seventy 
years. 

Pathology. — In  the  descending  form  of  tuberculosis  the  condition  in  the 
beginning  is  usually  unilateral,  but  later  in  the  course  of  the  disease  the  other 
kidney  becomes  infected  (ascending  infection  from  the  bladder).  In  the  ascend- 
ing form  the  infection  is  usually  bilateral.  In  hsematogenous  infection  (de- 
scending) the  tubercles  are  first  formed  about  the  glomeruli  and  the  minute 
vessels,  but  these  deposits  may  take  place  in  any  part  of  the  gland.  They 
gradually  break  down,  and  from  them  the  infection  is  spread  by  the  blood- 
and  lymph-channels  and  by  contiguity  ("Plate  X).  The  mucous  membrane 
of  the  calyces  and  pelvis  becomes  involved,  either  by  distinct  tuberculous 
formations  or  by  diffuse  infiltration.  The  breaking  down  of  the  aggregated 
tubercles  leads  to  the  formation  of  cavities — the  so-called  tuberculous  cysts 
(Fig.  346).  The  contents  are  generallv  a  yellowish-gray,  sometimes  blood- 
tinged  fluid  of  thick  consistency  and  urinous  odor,  compounded  of  pus,  urine, 
blood,  renal  tissue,  tuberculous  matter,  and  detritus,  with  occasional  collec- 
652 


RENAL  TUBERCULOSIS  AND  FISTULyE 


653 


tions  of  lime  salts,  phosphates,  and  cholesterin.  Tubercle  bacilli  can  usually 
be  demonstrated  in  the  wall  of  the  cysts,  but  they  are  rarely  to  be  found  in 
the  contents. 

Mixed  infection  is  the  rule  in  the  advanced  cases,  and  pus  organisms  are 
found  in  the  cyst  contents.  The  capsule  of  the  kidney  becomes  sclerosed  and 
thickened,  and  may  present  either  a  diffuse  or  a  localized  tuberculous  infiltra- 
tion; it  is  tightly  adherent  to  the  gland.  The  total  bulk  of  the  organ  may 
be  considerably  enlarged  by  massive  deposits  and  the  capacity  of  the  pelvis 
much  reduced;  or  after  extensive  degeneration  there  may  be  marked  reduc- 
tion in  the  size  of  the  organ,  due  to  contraction  of  the  connective  tissue  and 


Fig.  346. — Advanced  tuberculosis  of  the  kidney.  Typical  exposition  of  "the  proc- 
ess of  multiple  cavity  formation.  (Laboratory  of  Surgical  Pathology,  University  of 
Pennsylvania.) 

•the  capsule.  In  the  course  of  time  the  ureter  is  commonly  affected,  and  its 
lumen  may  be  so  narrowed  that  the  tuberculous  kidney  becomes  pyonephrotic. 

The  perinephric  tissue  is  always  thickened,  and  may  become  tuberculous 
either  by  extension  from  the  true  capsule,  lymphatic  infection,  or  the  bursting 
of  one  of  the  renal  cysts.  Thus  perinephric  abscess  often  complicates  renal 
tuberculosis. 

In  cases  of  ascending  tuberculosis,  where  a  hydronephrosis  often  precedes 
the  tuberculous  infection,  the  process  commences  in  the  mucous  membrane 
of  the  pelvis,  attacks  the  apices  of  the  pyramids,  and  gradually  extends  towards 


554  GENITO-URINARY  SURGERY 

the  cortex,  which  it  involves  less  profoundly  than  is  the  case  in  haematogenous 
infection.  Obstruction,  with  the  development  of  hydronephrosis  and  pyone- 
phrosis, is  commoner  in  the  ascending  form. 

Bilateral  tuberculosis  in  the  majority  of  cases  begins  on  the  two  sides  at 
different  times,  there  being  sometimes  an  interval  of  years  between  the  time 
of  infection  of  the  two  organs.  When  but  one  kidney  is  infected  the  other 
is  imperilled  in  two  ways — the  danger  of  tuberculous  infection,  and  the  danger 
of  poisoning  with  the  development  of  a  nephritis  as  a  result  of  the  elimina- 
tion of  toxins  generated  in  the  already  infected  kidney.  It  has  been  repeatedly 
observed  that  the  urine  of  the  "good"  kidney  has  improved  after  the  removal 
of  its  infected  fellow. 

Symptoms. — There  are  usually  no  symptoms  so  long  as  the  renal  sub- 
stance alone  is  affected,  but  pain  develops  when  the  mucous  membrane  of  the 
calyces  becomes  involved  or  when  an  abscess  empties  into  the  pelvis;  hence 
this  is  often  the  first  symptom  (Rosenstein).  The  pain  is  at  first  dull  and 
aching,  and  is  referred  to  the  lumbar  region.  At  times  severe  paroxysms  occur 
(renal  colic),  and  the  pain  is  reflected  to  the  penis  and  testicles.  Pain  may  be 
increased  by  motion  and  position.  Some  patients  acquire  a  habit  of  lateral 
curvature,  with  the  concavity  towards  the  affected  side,  since  this  position 
lessens  their  suffering.  Urination  may  occasion  severe  pain,  referred  to  the 
vesical  neck;  this  is  to  be  interpreted  as  a  sign  of  vesical  involvement. 

Urinary  symptoms  may  occur  early;  later  they  are  constant.  Undue  fre- 
quency of  urination  and  slight  urgency  or  incontinence  are  symptoms  which, 
in  the  absence  of  obvious  cause,  should  always  arouse  suspicion  of  tuber- 
culosis. According  to  Kelly,  these  are  the  first  symptoms  in  about  70  per 
cent,  of  cases,  but  Rovsing  states  that  in  his  series  60  per  cent,  of  his  patients 
consulted  physicians  on  account  of  pain  in  the  region  of  the  kidney,  emacia- 
tion, weariness,  or  turbidity  of  the  urine  long  before  the  bladder  symptoms 
set  in.  Later  in  the  disease  the  fearful  strangury  and  tenesmus  of  tubercu- 
lous cystitis  are  almost  unmistakable. 

Early  in  the  disease  the  quantity  of  urine  may  be  normal,  but  is  often  in- 
creased, constituting  polyuria.  As  soon  as  the  mucous  membrane  becomes 
affected,  pus  and  blood  appear  in  the  urine. 

Hsematuria  is  usually  slight  and  intermittent;  it  may  be  constant,  but 
there  is  much  less  blood  than  in  malignant  disease  or  calculous  pyelitis.  The 
appearance  of  a  few  red  blood-cells  in  the  urine  of  a  patient  complaining  of 
lumbar  pain  and  frequency  is  highly  suggestive  of  tuberculosis.  After  the 
abscesses  have  once  opened  into  the  pelvis  pyuria  is  constant,  except  when 
the  ureter  becomes  blocked;  this  complication  is  of  frequent  occurrence,  but 
the  obstruction  is  rarely  permanent.  In  a  few  hours  or  days  the  blocking 
material  becomes  dislodged,  and  there  follows  a  profuse  gush  of  urine,  loaded 
■with,  pus  and  detritus.  At  times  the  tuberculous  matter  in  the  urine  may 
be  so  bulky  that  it  is  with  difficulty  voided. 

In  those  cases  in  which  the  ureter  is  permanently  occluded  a  closed  pyone- 
phrosis of  tuberculous  origin  results.  If  this  occurs  early  in  the  disease,  the 
resultant  tumor  is  large;  if  late,  after  destruction  of  much  renal  tissue  has  oc- 
curred and  a  certain  amount  of  scar  tissue  has  been  formed,  the  tumor  is  apt 


RENAL  TUBERCULOSIS  AND  FISTULA 


655 


to  be  smaller  than  the  normal  kidney.  Calcareous  deposits  may  form  in 
caseous  tuberculous  material  sufficiently  dense  to  throw  skiagraphic  shadows 
(Fig.  347),  which  may  be  mistaken  for  those  of  calculi. 

Albuminuria  is  present  both  because  of  the  blood  and  pus  in  the  urine, 
and  on  account  of  the  nephritis  which  is  set  up.  The  albuminuria  may  be 
an  early  feature.     A  sterile  renal  pyuria  is  indicative  of  renal  tuberculosis, 


Fig.  347. — Tuberculosis  of  the  kidney.  A  calcareous  deposit  in  the  caseated  area 
casts  a  shadow  in  the  radiogram,  readily  mistaken  for  calculus.  (Skiagram  taken  by  Dr. 
H.  K.  Pancoast.) 

while  a  renal  pyuria  containing  the  pyogenic  bacteria  points  to  a  pyelitis, 
etc.,  which  may  or  may  not  have  a  tuberculous  element.  The  urine  is  usually 
acid  in  the  absence  of  pyonephrosis  or  bladder  infection;  after  the  advent  of 
cystitis  or  when  there  is  retention  in  the  kidney  pelvis,  with  mixed  infection, 
it  is  alkaline.  It  is  turbid  according  to  the  amount  of  pus  it  contains,  and  col- 
ored according  to  the  amount  of  blood. 


^56  GENITO-URINARY  SURGERY 

Microscopically,  pus  and  blood  are  frequently  found,  but  clots  are  rare. 
Hyaline  casts  are  commonly  present.  Colombino  asserts  that  deformed  leu- 
cocytes are  particularly  characteristic.  Epithelial  cells  from  the  kidney  and 
pelvis  are  constant  in  the  urine  of  cases  with  advanced  lesions;  renal  tissue 
is  occasionally  seen;  connective  tissue  and  elastic  fibres  are  sometimes  found, 
and  are  of  great  diagnostic  value,  as  are  the  little  clumps  of  meal-like  detritus 
which  look  like  conglomerated  nuclei  and  resist  all  reagents. 

Tubercle  bacilli  should  be  sought  for  in  all  cases;  especial  care  must  be 
taken  that  the  urine  is  fresh  and  that  the  smegma  bacillus  is  excluded. 

Physical  examination  reveals  symptoms  of  diagnostic  value.  In  many 
cases  a  tumor  is  noted  in  the  loin,  due  to  actual  renal  enlargement,  to  peri- 
nephric abscess,  or  to  a  pyonephrosis.  This  tumor  may  be  outlined  by  per- 
cussion posteriorly,  and  may  be  felt  through  the  abdominal  walls.  It  may 
feel  smooth  or  nodular,  may  fluctuate,  and  is  generally  tender  on  pressure. 
The  enlarged  ureters  are  sometimes  palpable.  Should  the  left  kidney  be  the 
one  affected,  the  spleen  may  be  pushed  forward  and  the  real  trouble  thus 
obscured.  Cystoscopic  examination  will  frequently  show  cedematous  pouting  of 
the  ureteral  eminence  with  hyperaemia  or  even  erosions  about  its  orifice  on 
the  side  affected   (see  Chapter  V). 

The  patient  ultimately  suffers  from  progressive  anaemia  and  digestive  dis- 
turbances, with  emaciation  and  cachexia.  Irregular  fever  may  be  present, 
and  often  assumes  a  hectic  type.  Other  tuberculous  lesions  commonly  de- 
velop. 

Diagnosis. — The  diagnosis  of  renal  tuberculosis  is  founded  upon — (1)  the 
demonstration  of  the  presence  of  tubercle  bacilli,  by  microscopic  examination 
or  inoculation;  (2)  the  cystoscopic  appearance  of  the  bladder,  taken  together 
with  a  decrease  in  functional  activity,  particularly  as  demonstrated  by  the 
indigocarmJn  test;  (3)  the  presence  of  pain  in  the  region  of  the  kidney; 
(4)  vesical  irritability;  (5)  slight,  transitory,  apparently  causeless  hsematuria; 
(6)  pyuria  developed  apparently  without  sufficient  cause,  and  persisting;  (7) 
an  otherwise  inexplicable  polyuria;  (8)  the  tubercuUn  test;  (9)  the  forma- 
tion of  a  lumbar  tumor;  (10)  the  development  of  tuberculous  lesions  in  other 
parts  of  the  body,  particularly  in  the  genito-urinary  tract;  (11)  a  tuberculous 
family  history;    (12)   the  development  of  tuberculous  cachexia. 

The  only  single  sign  which  is  absolutely  diagnostic  is  the  finding  of  the 
tubercle  bacilli;  since  these  microorganisms  cannot  be  differentiated  from 
smegma  bacilli  by  staining  reaction,  in  collecting  the  urine  care  must  be  taken 
to  avoid  contamination  from  the  surface  of  the  glans  or  the  foreskin. 

The  cystoscopic  appearance  of  the  bladder  is  sometimes  distinctive,  at 
others  the  reverse  (see  p.  49),  and  must  therefore  be  taken  in  connection 
with  other  factors  in  forming  an  opinion. 

The  propriety  of  using  the  ureteral  catheter  in  cases  of  tuberculosis  has 
been  disputed,  on  the  ground  that  it  is  so  possible  to  carry  tubercle  bacilli 
into  the  sound  ureter,  thus  implanting  the  disease  in  the  sound  kidney.  It 
seems  improbable  that  a  mistaken  diagnosis  would  result  if  a  fair  amount  of 
urine  be  allowed  to  flow  through  the  catheter  before  the  specimen  is  collected, 
and  cases  of  infection  of  a  sound  kidney  occurring  in  this  manner  have  not 
been  reported. 


RENAL  TUBERCULOSIS  AND  FISTULA  657 

It  is  of  the  utmost  importance  to  ascertain  not  only  which  is  the  more 
diseased  kidney  (this  can  usually  be  done  by  means  of  the  indigocarmin  test 
without  the  insertion  of  a  catheter),  but  whether  or  not  the  opposite  kidney 
is  also  tuberculous.  The  presence  of  albumin  and  casts  in  the  urine  of  the 
remaining  kidney  is  not  a  contra-indication  to  the  performance  of  nephrectomy, 
nor  is  a  reduction  in  its  urea  excretion,  as  these  may  be  due  to  the  influ- 
ence of  its  tuberculous  mate,  and  may  clear  up  promptly  after  nephrectomy, 
but  it  is  inadvisable  to  operate  in  the  presence  of  a  bilateral  tuberculosis.  When 
catheterization  is  impossible  on  account  of  the  condition  of  the  bladder-wall, 
ureteral  strictures,  or  the  pain  occasioned,  dependence  must  either  be  placed 
on  the  observation  of  indigocarmin  (chromo-ureteroscopy),  or  both  kidneys  must 
be  exposed  and  examined  as  advised  by  Rovsing. 

The  tuberculin  test  may  merely  indicate  that  there  is  a  tuberculous  lesion 
in  the  body,  or  by  the  focal  reaction,  the  kidney  becoming  more  tender  and 
the  existent  symptoms  more  marked,  the  tuberculous  condition  of  this  organ 
may  be  clearly  indicated.  The  test  performed  by  the  subcutaneous  injection 
of  Old  Tuberculin  is  the  only  dependable  one;  the  usual  initial  dose  is  0.5 
mg. ;  should  no  reaction  follow  this  injection,  doses  of  L25,  2.5,  and  5  mg. 
may  be  given,  at  intervals  of  not  less  than  three  days.  A  rise  of  temperature 
of  not  less  than  one  degree,  together  with  focal  symptoms,  is.  interpreted  as 
a  positive  reaction;  should  a  questionable  reaction  occur  it  is  better  to  repeat 
the  same  dose  before  giving  a  greater  quantity. 

The  development  of  a  lumbar  tumor  is  of  diagnostic  value  only  when  it 
is  associated  with  other  characteristic  symptoms  of  renal  tuberculosis.  There 
are  no  peculiarities  of  the  tuberculous  enlargement  which  would  enable  the 
surgeon  to  suspect  the  nature  of  the  growth  from  physical  examination.  When 
the  tuberculous  kidney  becomes  infected  with  pus  microorganisms — and  this 
takes  place  in  nearly  all  cases — the  symptoms  are  simply  those  of  a  pyelitis, 
pyelonephritis,  or  suppurative  nephritis,  the  diagnosis  as  to  the  underlying 
tuberculous  nature  of  the  affection  then  resting  upon  the  result  of  bacterio- 
logical examination. 

Calculus,  with  or  without  pyonephrosis,  pyogenic  infections  of  the  kidney, 
spinal  caries  with  abscess  formation,  with  or  without  sinuses,  tuberculous 
infections  of  other  parts  of  the  body,  and  cystitis,  rnust  all  be  considered  and 
ruled  out  by  appropriate  measures. 

Prognosis. — Untreated,  the  ultimate  prognosis  of  renal  tuberculosis  is  bad. 
A  few  cases  heal;  a  few  progress  so  slowly  that  there  may  be  a  fair  degree 
of  health  for  ten  to  twenty  years.  Yet  it  is  not  proper  to  delay  operation 
in  the  hope  that  the  use  of  tuberculin  will  bring  about  a  cure;  this  agency 
should  be  used  only  when  the  disease  is  bilateral. 

The  prognosis  in  unilateral  tuberculosis  is  good  in  proportion  to  the  prompt- 
ness with  which  the  diseased  kidney  is  removed.  When  the  tuberculous  infec- 
tion is  confined  to  one  kidney,  recovery  is  prompt,  complete,  and  lasting; 
even  when  the  bladder  is  obviously  involved,  a  radical  cure  may  be  ex- 
pected in  more  than  half  the  cases.  Nor  is  a  complicating  pulmonary  tuber- 
culosis in  itself  a  contra-indication  to  nephrectomy. 
42 


658  GEXITO-URIXARY  SURGERY 

Treatment. — When  both  kidneys  are  affected  h\-gienic  measures  and  tuber- 
cuhn  therap}-  are  indicated.  If  one  kidney  has  been  converted  into  a  pus- 
sac,  with  practically  no  remaining  renal  function,  the  removal  of  this  sac 
would  seem  indicated  rather  than  drainage  through  an  incision,  since  the  latter 
procedure  always  results  in  the  formation  of  a  lasting  and  troublesome  fistula. 

In  unilateral  tuberculosis,  nephrectomy  should  be  performed,  through  an 
incision  large  enough  for  the  free  exposure  of  the  kidney  and  its  pedicle.  In 
advanced  cases  it  may  be  found  that  the  capsule  of  a  kidney  which  has 
become  degenerated  as  the  result  of  tuberculous  pyelonephritis  has  contracted 
dense  adhesions  to  surrounding  structures,  and  that  the  loosening  of  these 
adhesions  may  be  impossible  without  opening  the  peritoneum,  tearing  large 
vessels,  or  injuring  neighboring  organs.  In  such  cases  it  is  advisable  to  prac- 
tise subcapsular  nephrectomy. 

The  ureter  should  be  ligated,  cauterized,  and  anchored  in  the  wound  at 
some  distance  from  the  peritoneum.  Ureterectom}^  is  not  advisable  as  a  pri- 
man.'  operation,  as  in  the  majorit}"  of  cases  spontaneous  heahng  takes  place. 
In  a  few  cases,  however,  on  account  of  the  persistence  of  vesical  disease  or 
a  lumbar  fistula,  a  secondary  ureterectom}'  becomes  necessary. 

REXAL  FISTULA 

Fistulee  may  form  spontaneously  as  a  result  of  the  rupture  of  abscesses 
secondary  to  pyonephrosis,  pyelonephritis,  or  perinephritis,  or  may  be  caused 
by  traumatism  or  surgical  intervention.  They  may  pass  down  to  the  kidney- 
surface,  to  its  glandular  substance,  or  into  its  pelvis. 

Fistulas  are  named  in  accordance  ^dth  their  direction  and  points  of  open- 
ing as  reno-cutaneous,  reno-gastric,  reno-intestinal,   and  reno-pulmonary. 

Reno-cutaneous  fistulae  usualty  open  in  the  lumbar  or  the  inguinal  region; 
their  course  is  fairh*  direct. 

Reno-gastric  fistulse  are  extremely  rare.  Duplay  and  Reclus  quote  Mar- 
quezy  as  authorit}*  for  the  statement  that  there  have  been  three  instances  in 
which  kidney  stones  were  expelled  through  the  mouth. 

Reno-intestinal  fistulae  are  comparatively  frequent,  particularly  those  open- 
ing into  the  colon. 

The  causes  of  fistulae  are  imperfect  drainage,  the  presence  of  a  foreign 
body,  as  a  calculus  or  a  drainage-tube,  continuous  profuse  suppuration,  as 
in  simple  or  tuberculous  pyelonephritis,  and  the  constant  escape  of  urine,  as 
in  wounds  of  the  pelvis  or  of  the  ureter.  Operative  fistulae  rarely  develop 
except  when  infected  tissues  are  involved  in  the  incision,  or  the  ureter  is  im- 
permeable. 

Symptoms. — The  most  obvious  S3"mptom  of  fistula  is  the  presence  of  an. 
ulcerating  opening  from  which  escapes  either  urine  or  pus.  Because  of  the 
continuous  discharge,  there  are  usually  marked  er3^thema  and  dermatitis  about 
the  opening.  \Mien  these  fistulae  are  of  long  standing,  diverticula  are  formed, 
the  walls  become  rigid,  and  the  tract,  though  fairh^  direct,  is  sufficiently  tortu- 
ous to  prevent  the  easy  introduction  of  a  probe. 

Reno-intestinal  fistulae  are  suggested  by  vomiting  or  purging  of  pus  and 
urine.      Reno-bronchial   fistulae   are   characterized   by   an    initial    profuse   dis- 


RENAL  TUBERCULOSIS  AND  FISTULA  659 

charge  of  pus,  followed  by  symptoms  much  like  those  of  a  purulent  pleurisy 
which  has  broken  into  a  bronchus. 

Prognosis. — In  the  absence  of  tuberculosis,  the  prognosis  of  renal  fistulae 
is  favorable  when  they  open  on  the  surface;  there  is  even  a  fair  prospect 
of  spontaneous  cure.  These  fistulae  exhibit  a  tendency  to  contract  slowly, 
thus  rendering  drainage  insufficient.  Exceptionally,  especially  in  tuberculous 
cases,  there  is  a  discharge  so  profuse  that  in  itself  it  is  exhausting  to  the 
patient. 

Treatment. — Preventive  treatment  of  fistulae  lies  in  prompt  intervention 
in  cases  of  renal  or  perirenal  suppuration.  When  a  fistula  has  formed  and 
persists  in  spite  of  proper  treatment,  free  direct  drainage  is  indicated,  fol- 
lowed by  gauze  packing  and  an  effort  to  make  the  wound  heal  from  the 
bottom.  Should  the  fistula  discharge  urine,  treatment  is  first  directed  towards 
rendering  the  ureter  permeable  and  of  normal  calibre.  When  this  is  accom- 
plished, the  kidney  may  be  exposed  and  freed  from  its  attachments,  the  walls 
of  the  renal  tract  excised,  the  wound  closed  by  catgut  suture,  and  the  parietal 
tract  treated  in  the  same  way. 

If  the  ureter  cannot  be  rendered  pervious,  or  if  the  fistula  comes  from 
a  hopelessly  disorganized  pyelonephritic  kidney,  nephrectomy  is  indicated,  pro- 
vided the  other  kidney  is  healthy. 


CHAPTER  XXX 

HYDRONEPHROSIS  (URONEPHROSIS) 

This  is  a  condition  characterized  by  distention  of  the  kidney  pelvis  with 
fluid,  usually  urine.  Morris,  however,  has  recorded  a  case  in  which  the  fluid 
was  composed  wholly  of  water  and  sodium  chloride,  without  a  trace  of  urea 
or  any  other  characteristic  of  urine.  This  absence  of  urea  was  probably  due 
to  pressure-atrophy  of  the  epithelium  of  the  tubules;  the  fluid  of  a  hydrone- 
phrosis commonly  contains  less  than  half  the  urea  of  normal  urine.  Hydrone- 
phrosis is  associated  with  pressure-atrophy  of  the  kidney  and  interstitial  nephri- 
tis, the  gland  and  its  pelvis  becoming  converted  into  a  fibrous,  thick-walled  sac, 
in  which  the  fluid  is  contained.  The  cause  of  hydronephrosis  is  obstruction  to 
the  flow  of  urine  through  any  portion  of  the  urinary  tract;  this  results  in  dis- 
tention and  paresis  of  the  pelvic  and  ureteral  muscles. 

Hydronephrosis  may  be  congenital  or  acquired,  permanent  or  intermittent, 
imilateral  or  bilateral,  partial  or  total.  In  permanent  hydronephrosis  the  dis- 
tention is  continuous;  in  the  intermittent  form  of  the  affection,  often  associated 
with  movable  kidney,  there  are  periods  during  which  the  obstruction  is  re- 
lieved and  the  retained  fluid  escapes,  usually  into  the  bladder.  Partial  hydro- 
nephrosis is  caused  by  blocking  of  one  or  more  calyces;  this  may  be  due  to 
stone  or  to  cicatricial  contraction.  Total  hydronephrosis  results  from  obstruc- 
tion of  the  pelvic  orifice  or  of  the  tract  below;  stone  is  the  common  cause, 
though  ureteral  kinks,  strictures,  blood-clots,  masses  of  coherent  pus,  fragments 
of.  tissue,  surgical  ligatures,  or  parasites  may  occasion  obstruction. 

Congenital  hydronephrosis  may  be  unilateral  or  bilateral.  Among  the 
causes  are  imperforate  urethra  (Fig.  348)  or  ureter.  Malformation,  folds  or 
duplicatures  of  the  mucous  membrane  at  the  vesical  orifice,  congenital  tumors  of 
the  bladder,  ureters,  or  neighboring  organs,  movable  kidney,  and  obstruction  by 
anomalous  blood-vessels  of  the  kidney,  are  occasional  causes. 

Congenital  strictures  usually  entirely  obliterate  the  ureters.  There  may  be 
a  narrowing  at  the  uretero-pelvic  junction,  or  even  a  valvular  formation  here. 
Later  in  life  there  is  sometimes  an  obstruction  at  this  point,  caused  by  the 
inflamed  mucous  membrane,  which  Kiister  states  slides  dowTiward  from  its 
attachment,  thus  creating  a  valve.  The  ureters  sometimes  leave  the  pelvis 
obliquely  or  at  an  angle  unfavorable  to  free  drainage.  This  conformation 
may  be  congenital  or  may  be  due  to  gradual  dilatation  of  the  pelvis.  Or  the 
ureter  may  leave  the  pehas  at  a  point  higher  than  normal,  thus  encouraging 
retention  of  urine  and  distention. 

If  the  disease  is  bilateral  it  is  rapidly  fatal.  Hydronephrosis  may  be 
present  at  birth,  or  may  appear  subsequently  because  of  congenital  deformity. 
When  the  disease  is  congenital  the  dilatation  usually  attains  proportionally 
a  much  greater  size  than  when  it  is  acquired.  Even  though  the  congenital 
obstruction  is  caused  by  an  impervious  ureter,  the  kidney  does  not  atrophy, 
660 


HYDRONEPHROSIS  (URONEPHROSIS) 


661 


since  during  intra-uterine  life  it  secretes  much  more  slowly  than  after  birth, 
and  consequently  intra-renal  pressure  is  not  developed  with  sufficient  rapidity 
to  arrest  secretion  before  the  delicate  pelvic  and  ureteral  tissues  have  become 
relaxed  and  overstretched. 

The  treatment  is  the  same  as  that  of  acquired  hydronephrosis.  When  the 
hydronephrosis  is  due  to  stricture  or  to  valve-formation,  lumbar  incision  fol- 
lowed by  an  attempt  to  remove  the  obstruction,  is  in  order.     Should  the  ob- 


FiG.  348. — Congenital  bilateral  hydronephrosis.  The  greatly  distended  kidneys  and 
bladder  completely  fill  the  abdominal  cavity.  The  cause  of  the  condition  is  a  congenitally 
imperforate  urethra.  (No.  2012.  Specimen  in  the  Laboratory  of  Surgical  Pathology,  Univer- 
sity  of   Pennsylvania.) 

struction  be  irremediable,  permanent  drainage  of  the  pelvis,  or,  if  the  disease 
is  unilateral,  nephrectomy,  is  indicated. 

x\cQUiRED  HYDRONEPHROSIS  IS  most  frequent  in  women,  probably  because 
they  are  so  commonly  subject  to  pelvic  disease  and  movable  kidneys.  It 
may  be  due  to  pelvic  tumors,  particularly  those  of  a  cancerous  nature,  dis- 
placements of  the  womb,  pelvic  inflammations,  vesical  neoplasms,  traumatism, 
unnatural  mobility,  or  ptosed  position  of  the  kidney,  intra-ureteral  blockage 


^562  GENITO-URINARY  SURGERY 

by  calculi,  tumors,  or  pus,  stricture  of  the  iirethra,  enlarged  prostate,  and 
irritable  bladder.  This  last  condition  is  operative  because  the  frequent  act 
of  micturition  has  a  tendency  constantly  to  close  the  vesico-ureteral  outlets, 
producing  backward  pressure  upon  the  pelvis  of  the  kidney. 

Of  six  hundred  and  sixty-five  cases  tabulated  by  Newman,  stricture  of 
the  urethra  and  enlarged  prostate  and  hypertrophy  of  the  bladder  were  found 
to  be  the  cause  in  one  hundred  and  ninety-five  bilateral  and  thirty-nine  uni- 
lateral cases  of  hydronephrosis.  Next  in  order  of  frequency  came  tumors  of 
the  pelvic  organs,  causing  compression  of  the  ureters.  From  this  alone  there 
were  one  hundred  and  forty-three  bilateral  and  forty-one  unilateral  cases. 
Renal  calculus  produces  unilateral  hydronephrosis  more  often  than  any  other 
of  the  causes  noted,  fifty-one  cases  being  due  to  this  alone;  it  was  found  to 
be  the  cause  of  only  seventeen  cases  of  bilateral  dilatation. 

In  a  certain  number  of  cases  observed  at  postmortem  examinations  no 
causes  have  been  discovered.  These  may  have  been  due  to  the  acute  angle 
of  exit  of  the  ureter  from  the  pelvis  or  to  undue  irritability  of  the  ureter. 

Pathology. — The  effect  of  hydronephrosis  upon  the  kidney  structure  de- 
pends upon  the  completeness  and  the  duration  of  the  obstruction.  Excep- 
tionally the  dilatation  is  confined  solely  to  the  pelvis.  Usually  the  kidney 
is  involved  sooner  or  later,  forming,  with  the  pelvis,  a  rounded,  irregularly 
nodulated  tumor,  varying  greatly  in  size.  Even  in  enormously  dilated  kidneys 
there  are  usually  some  remnants  of  secreting  substance.  As  a  rule,  the  walls 
of  the  cyst  are  made  up  of  fibrous  tissue.  Such  cysts  have  been  known  to 
contain  several  gallons. 

Griffiths  has  carefully  studied  the  histological  changes  produced  by  hydrone- 
phrosis. There  are  two  distinct  processes,  one  the  result  of  pressure  limited 
to  the  tissue  pressed  upon;  the  other  a  degeneration  identical  with  that  seen 
in  chronic  interstitial  nephritis,  due  in  part  to  the  distention  of  the  pelvis, 
which  by  compressing  and  stretching  the  renal  vessels  as  they  pass  into  the 
kidney  interferes  with  the  nutrition  of  the  whole  organ.  Distention  of  the 
pelvis  takes  place  mainly  in  a  forward  direction,  pushing  the  renal  vessels 
which  lie  in  front,  and  thus  stretching  and  flattening  them.  In  the  later 
stages  of  hydronephrosis  there  is  thickening  of  the  intima,  and  even  of  the 
media,  with  the  formation  of  fibrous  connective  tissue,  thus  contributing  to 
further  diminution  in  the  calibre  of  the  channels  which  supply  the  kidneys 
with  blood.  Occasionally  thrombi  develop  in  these  vessels.  The  cortical  sub- 
stance of  the  kidney  is  the  slowest  to  disappear. 

Finally  the  whole  secreting  substance  is  converted  into  connective  tissue. 
The  perinephric  fat  is  infiltrated  and  adherent.  The  dilated  larger  excretory 
tubes  persist  for  some  time;  at  last  even  traces  of  these  disappear,  the  hydrone- 
phrotic  kidney  forming  a  huge  sac  (Fig.  349),  sometimes  incrusted  with  urinary 
salts.  The  participation  of  the  ureter  depends  upon  the  seat  of  obstruction. 
The  contents  of  the  hydronephrotic  sac  are  water,  with  a  diminished  quantity 
of  urinary  salts  and  urea,  and  often  a  small  amount  of  blood,  desquamated 
epithelium,  leucocytes,  casts,  and  albumin.  The  solids  are  sometimes  precipi- 
tated, forming  a  thick,  semi-liquid,  brownish  mass.  The  sound  kidney  be- 
comes Tiypertrophied.     Symptoms  are  at  times  completely  absent,  and,  pro- 


HYDRONEPHROSIS  (URONEPHROSIS) 


663 


vided  the  other  kidney  undergoes  compensatory  growth,  there  may  be  no  inter- 
ference with  the  general  health. 

Intermittent  or  relapsing  hydronephrosis  is  characterized  by  an  occasional 
partial  or  complete  evacuation  of  the  contents  of  the  dilated  kidney  pelvis, 
followed  by  the  passage  of  a  large  quantity  of  urine  from  the  bladder.  In 
one  case,  reported  by  Gintrac,  the  tumor  was  wont  to  subside  suddenly  by 
discharging  into  the  colon,  the  subsidence  being  followed  by  copious  watery  stools. 
The  usual  cause  of  intermittent  hydronephrosis  is  movable  kidney  the 
ureter  being  flexed  or  twisted,  and  remaining  partially  or  completely  impervious 

till  a  change  in  the  position  of  the  organ 
renders  its  duct  patulous  and  the  retained 
urine  freely  escapes. 

Occasionally  intermittent  hydrone- 
phrosis may  be  due  to  a  calculus,  which 
may  act  as  a  temporary  ball-valve,  closing 
the  ureteral  outlet  from  the  kidney,  but 
becoming  dislodged  when  the  pelvis  is 
much  dilated.  After  the  subsidence  of  the 
tumor  the  patient  may  be  free  from  symp- 
toms for  months,  or  even  years,  or  the 
hydronephrosis  may  recur  frequently. 

Bland  Sutton  calls  attention  to  the  dif- 
ficulty of  deciding  clinically  between  a 
very  large  hydronephrotic  cyst  and  an 
ovarian  or  parovarian  cyst,  since  cysts  of 
the  ovary  and  parovarium  sometimes 
rupture,  and  the  fluid  escaping  into  the 
peritoneum  is  absorbed  by  this  membrane 
and  rapidly  excreted  by  the  kidneys,  thus 
producing  the  characteristic  symptoms  of 
intermittent  hydronephrosis — i.e.,  tumor 
which  suddenly  disappears  and  is  promptly 
followed  by  diuresis. 

In  nearly  all  cases  of  hydronephrosis 
the  obstruction  is  not  complete — that  is, 
there  is  a  partial  escape  of  urine;  hence, 
as  a  rule,  there  is  intermittence  in  degree 
of  tension.  Clinically  the  term  intermit- 
tent is  applied  only  to  those  cases  in  which 
the  swelling  occasionally  disappears  completely. 

Terrier  and  Boudoin  collected  eighty-three  cases  of  intermittent  hydrone- 
phrosis. They  found  movable  kidney  the  usual  cause,  and  called  attention 
to  the  fact  that  the  disease  eventually  becomes  permanent,  owing  to  inflam- 
matory constrictions  and  adhesions  fixing  the  displaced  kidney. 

Symptoms. — Unless  sufficient  urine  is  retained  to  produce  a  distinct  tumor, 
there  may  be  no  symptoms  of  hydronephrosis.  The  obstruction  is  usually  of 
such  a  nature  that  retention  is  gradual  and  painless  in  its  onset,  and  dilata- 


FlG.  349. — Destruction  of  kidney  from 
hydronephrosis.  (Specimen  in  Philadelphia 
Hospital   Museum.) 


564  GENITO-URINARY  SURGERY 

tion  of  the  kidney  and  its  pelvis  is  not  suspected  untU  examination  shows  a 
smooth,  rounded,  movable,  fluctuating  tumor  placed  behind  the  colon  and 
projecting  into  the  abdominal  cavity.  The  fluctuation  can  be  detected  only 
in  large  accumulations.  Often  there  is  a  sense  of  weight  and  dragging,  and 
sometimes  there  are  distinct  attacks  of  pain,  resembHng  kidney  coHc,  due  to 
sudden  increase  of  tension.  Hydronephrosis  develops  without  fever,  in  the 
absence  of  infection.  The  intermittent  form  of  the  disease  is  characterized 
by  the  appearance  of  a  tumor  of  rapid  growth,  which  gives  rise  to  pain,  and 
by  sudden  disappearance  of  the  tumor,  followed  by  polyuria.  Pain  which 
develops  during  the  growth  of  the  tumor  may  be  extremely  severe,  and  may 
present  all  the  features  of  kidney  colic.  The  intermission  is  sometimes  as 
regular  as  are  the  recurrences  of  malarial  paroxysms. 

Diagnosis. — This  is  based  on  the  detection  of  a  fluctuating  tumor  primar- 
ily occupying  the  kidney  region.  When  hydronephrosis  is  of  such  small  di- 
mensions that  it  cannot  be  felt  by  palpation,  diagnosis  is  based  on  ureteral 
catheterization,  injection,  and  pyelography. 

Large  hydronephrotic  sacs  are  readily  confounded  with  ovarian  cysts,  espe- 
cially when  the  evolution  of  the  tumor  and  its  position  while  still  small  are 
unknown.  It  can  readily  be  seen  that  a  sac  containing  thirty  gallons,  as  in 
a  case  reported  by  Bland  Sutton,  practically  fills  the  abdominal  space.  Dif- 
ferential diagnosis  may  be  impossible,  and  it  has  frequently  happened  that 
diagnosis  has  been  made  only  after  incision  for  operation. 

By  means  of  the  cystoscope,  with  and  without  the  addition  of  the  X-ray, 
much  valuable  information  is  obtainable.  When  possible,  the  catheter  should 
be  passed  into  the  pelvis,  its  entrance  being  evidenced  by  a  more  rapid  flow; 
in  a  few  cases,  generally  large  tumors,  it  is  impossible  to  reach  the  pelvis, 
with  the  catheter.  If  the  pelvis  is  entered,  the  contained  fluid  should  be 
drained  off  and  measured,  and  if  any  doubt  remains  as  to  the  condition 
Kelly's  suggestion  of  injecting  the  pelvis  with  a  solution  of  methylene  blue 
may  be  carried  out,  the  ureteral  orifice  being  watched  to  note  any  back-flow 
of  the  solution,  the  injection  being  continued  till  pain  is  occasioned;  the  fact 
that  this  pain  is  of  the  same  character  as  that  previously  complained  of  is 
of  great  significance.  In  those  cases  in  which  there  is  still  doubt  as  to  the 
condition  of  the  kidney,  pyelography  should  be  used.  A  pelvic  capacity  of 
more  than  25  c.c.  with  blunting  of  the  calyces  is  indicative  of  hydronephrosis. 
(Figs.  350  and  351).  A  lessening  of  kidney  function  indicated  by  a  delayed 
elimination  of  indigocarmin  is  often  helpful  in  making  a  diagnosis. 

Prognosis. — The  prognosis  of  hydronephrosis  is  favorable  if  the  disease 
is  unilateral.  Spontaneous  cure  may  result,  probably  from  atrophy  of  the 
secreting  substance  of  the  kidney.  The  more  common  terminations  are  pyone- 
phrosis and  pyelonephritis.  When  the  disease  is  bilateral  (Fig.  352)  the  prog- 
nosis is  grave. 

Treatment. — The  essential  thing  in  the  treatment  of  hydronephrosis  is 
the  removal  of  the  obstruction  to  the  outflow  of  urine;  when  this  cannot  be 
done,  a  vicarious  outlet  must  be  established  or  nephrectomy  performed. 

Massage  and  manipulation  of  the  swelling  have  been  successful  in  over- 
coming the  obstruction  when   it  was  caused  by  impacted   calculus  or  kinks 


HYDRONEPHROSIS  (URONEPHROSIS:* 


665 


Fig.  350. — Hydronephrosis,  illustrating  mild  grade  of  the  condition.      Capacity  of  pelvis 
was  30  c.c.     (Skiagram  by  Dr.  H.  K.  Pancoast.) 


Fig.  351. — Huge  hydronephrosis.  Its  position, 
outline,  and  approximate  size  clearly  demonstrated  by 
colloidal  silver.  Note  sharp  bend  in  ureter  indicated  by 
arrows  over  spine.  At  operation  found  to  be  infected. 
(Mayo's   Clinics,   W.   B.  Saunders   Co.) 


Fig.  352. — Double  hydronephrosis 
secondary  to  concentric  hypertrophy  of 
bladder,  this  being  secondary  to  hyper- 
trophy  of   the  prostate  and   calculus. 


666 


GENITO-URINARY  SURGERY 


^pA^y^. 


AjNonvsJous  Blood -vessdlr- 

Fig.  353. — Hydronephrosis  trom  kinked 
ureter,  caused  by  anomalous  blood-vessels. 
(Mayo's  Clinics,  W.  B.  Saunders  Co.) 


Fig.  354. — Blood-vessels  cut  and  tied.  Patty 
fascial  flap  raised  and  ureteropelvic  juncture 
divided.     (Mayo's  Clinics,  W.  B.  Saunders  Co.) 


Pig.  355. — Plastic  operation  on  utero- 
pelvic  juncture  completed.  (Mayo's  Clinics 
W.  B.  Saunders  Co.) 


Fig.  356. — Fatty  fascial  flap  in  posi- 
tion, and  held  by  a  few  catgut  sutures. 
(Mayo's   Clinics,   W.  B.   Saunders   Co.) 


HYDRONEPHROSIS   (UROxNEPHROSIS)  667 

in  the  ureter  produced  by  movable  or  floating  kidney,  a  treatment  not  with- 
out danger,  and  usually  affording  but  temporary  relief.  A  properly  fitting 
abdominal  support  may   relieve  the  obstruction  incident  to  movable  kidney. 

Ureteral  catheterization  is  serviceable  when  retention  is  due  to  stricture 
of  the  ureter,  to  valve-formation,  or  to  an  anomalous  exit  of  the  ureter  from 
the  pelvis.  It  may  not  only  relieve  tension  but  may  prove  curative  in  case 
of  stricture.  In  using  the  ureteral  catheter  the  danger  of  converting  a  hydrone- 
phrosis into  a  pyonephrosis  must  be  appreciated  and  guarded  against. 

Aspiration  is  a  treatment  which  may  be  necessitated  when  the  urgency  of 
symptoms  calls  for  temporary  relief.  There  is  usually  a  reaccumulation  of 
fluid;  in  a  certain  number  of  cases  after  emptying  the  sac  twice  or  thrice 
the  secretion  has  ceased  and  the  cure  has  been  permanent.  This  is  probably 
due  to  the  fact  that  the  secreting  substance  of  the  kidney  has  been  com- 
pletely atrophied.  The  operation  is  not  free  from  risk  of  septic  infection  of 
the  sac  and  the  development  of  pyonephrosis.  Morris  advises,  when  no  par- 
ticular spot  is  suggested  by  discoloration  or  prominence,  that  the  needle  should 
be  driven  in,  on  the  left  side,  an  inch  in  front  of  the  last  intercostal  space. 
"If  there  is  no  indication  for  operating  elsewhere,  the  best  spot  to  select  when 
the  kidney  is  on  the  right  side  is  half-way  between  the  last  rib  and  the  crest 
of  the  ilium,  between  two  and  two  and  a  half  inches  behind  the  anterior 
superior  spine  of  the  ilium."  The  intestine  is  usually  in  front  of  the  tumor 
and  adherent  to  it,  and  may  be  wounded  if  the  puncture  is  made  too  far 
forward. 

Operative  treatment  will  be  required  in  the  majority  of  cases.  The  kid- 
ney should  usually  be  exposed  through  a  lumbar  incision  (the  transperitoneal 
route  being  used  only  for  very  large  tumors),  and  examined  to  determine  the 
cause  of  the  condition,  if  this  has  not  already  been  discovered  through  non- 
operative  means.  If  the  cause  is  removable,  this  is  naturally  the  course  to  fol- 
low, so  that  the  treatment  is  frequently  that  of  pelvic  or  ureteral  stone,  or 
of  movable  kidney,  or  ligation  and  division  of  an  anomalous  vessel;  or  it 
may  be  necessary  to  do  a  plastic  operation  on  the  pelvis  and  ureter;  or  more 
than  one  of  these  procedures  may  be  indicated.  Some  hesitancy  must  be 
felt  in  dividing  anomalous  renal  vessels  (Figs.  353,  354,  355,  and  356),  even 
though  they  be  the  cause  of  the  obstruction,  as  infarcts  of  the  kidney  are 
apt  to  result. 

When  the  obstruction  cannot  be  removed,  or  there  is  a  very  large  sac 
and  disorganized  kidney,  nephrectomy  should  be  performed,  provided  that  the 
opposite  kidney  is  functionally  sufficient;  otherwise  nephrotomy  or  nephrostomy 
is  indicated.  Nephrotomy  is  followed  by  a  persistent  fistula  in  over  fifty  per 
cent,  of  cases. 


CHAPTER  XXXI 

RENAL  TUMORS  AND  PARASITES 

Primary  tumors  of  the  kidney  are  not  common,  less  than  one  per  cent,  of 
mahgnant  tumors  taking  origin  here,  while  the  percentage  of  benign  neoplasms 
is  probably  even  smaller.  Classifications  of  renal  growths  are  far  from  satis- 
factory; there  is  considerable  variation  in  the  terms  whereby  the  same  condition 
is  described,  and  until  comparatively  recently  there  has  been  a  misconception 
as  to  the  nature  of  some  of  the  commoner  tumors,  so  that  the  older  reports  are 
valueless  for  purposes  of  statistical  study.  The  following  classification  is  sug- 
gested: 


Embryonal 


5enign 


{Teratoma 
Hypernephroma  (but  usually  malignant) 


{Hypernephroma     (Grawitzian    tumor,    nephrogenic 
mesothelioma). 
Mixed  tumor  (Wilms's  tumor,  embryoma  of  childhood). 
Rhabdomyoma 

{Lipoma 
Fibroma 
Angioma 


Solid 
(Nonepithelial) 


Malign  ant- Sarcoma- 


Round-cell 

Spindle-cell 

Fibro-sarcoma 

Angio-sarcoma 

Myxo-sarcoma 

Chondro-sarcoma 

Melano-sarcoma 


Solid 
(Epithelial) 


.       f  Adenoma 
Benign  j  Papilloma 

Malignant  I  Carcinoma  ,        .„      ,  .  ^ 

j  Papillary  cystadenoma  (papilloadenocarcinoma). 


l^.      .   [Multiple  retention 
I  Simple  jsingle  serous 
Cystic  j  Polycystic  degeneration  t 

Dermoid 
Echinococcus  (Hydatid) 

The  benign  tumors  of  the  kidney  are  of  little  importance  from  a  surgical 
standpoint.  They  rarely  reach  large  size,  and  seldom  give  rise  to  symptoms, 
being  usually  discovered  at  autopsy. 

Malignant  tumors,  when  primary,  are  unilateral;  when  secondary,  they 
may  be  bilateral.  They  are  found  both  in  early  childhood  and  in  adult  life, 
668 


RENAL  TUMORS  AND  PARASITES  669 

after  the  thirty-fifth  year,  but  seldom  in  the  intermediary  period.  This  is 
shown  in  the  following  tabulation  of  one  hundred  and  sixty  cases  prepared  by 
Kelynack: 

Up  to  one  year  of  age 12  cases 

From  one  to  two  years 23  cases 

From  two  to  three  years   ' 16  cases 

From  three  to  four  years 17  cases 

From  four   to   five   years 6  cases 

From   five   to   nine   years 10  cases 

From  nine  to  eighteen  years 0  cases 

From  eighteen  to  twenty-five  years 7  cases 

From  twenty-five-  to  thirty-five  years 8  cases 

From  thirty-five  to  forty-five  years 17  cases 

From  forty-five  to  fifty-five  years 22  cases 

From   fifty-five   to   seventy  years 22  cases 

Embryonal  Tumors. — Teratoma. — These  tumors,  together  with  all  benign 
tumors  of  the  kidney,  are  rare.  This  group  is  due  to  an  abnormality  in  the 
developing  embryo  whereby  there  is  a  displacement  of  parts  normally  found 
in  other  regions  of  the  body.     The  tumors  may  reach  considerable  size. 

Hypernephroma. — This  tumor,  when  benign,  is  of  small  size  and  encap- 
sulated. In  the  great  majority  of  cases,  however,  hypernephromata  are  dis- 
tinctly malignant,  though  they  do  not  metastasize  early. 

Prior  to  the  publication  of  Grawitz's  article  in  1883  these  growths  were 
not  grouped  together,  but  were  considered  to  be  lipomata  (on  account  of 
their  yellow  mottled  appearance),  or  sarcomata,  or  carcinomata.  Grawitz  ad- 
vanced the  theory  that  they  developed  from  adrenal  rests,  a  theory  which 
received  general  support  till  recently,  and  to  which  their  commonly  accepted 
name  is  due.  It  seems  probable,  however,  that  this  is  a  mistaken  hypothesis, 
and  that,  as  contended  by  Wilson,  these  tumors  develop  from  nephrogenic 
tissue  which  has  failed  to  form  a  connection  with  the  renal  pelvis  and  has 
lain  dormant  till  adult  life,  when  through  some  accident  of  trauma,  infectious 
irritation,  etc.,  it  has  been  stimulated  to  active  growth.  Accordingly,  mesothe- 
lioma or  nephrogenic  mesothelioma  is  a  more  descriptive  term  than  hyper- 
nephroma. 

The  tumors  vary  enormously  in  size,  being  sometimes  so  small  that  they 
are  indistinguishable  with  the  naked  eye,  sometimes  so  large  that  they  change 
the  conformation  of  the  abdomen.  The  smaller  specimens  have  a  grayish  or 
yellowish  appearance;  the  larger  ones  are  usually  mottled  and  of  a  yellowish 
hue,  at  least  in  some  regions.  The  consistency  is  much  softer  than  that  of 
carcinomata.     They  originate  in  the  cortex,  usually  near  the  lower  pole. 

A  distinct  capsule  surrounds  both  the  larger  and  smaller  growths  (Plate 
XI) ;  in  the  later  stages  this  may  be  broken  through,  with  secondary  involve- 
ment of  other  portions  of  the  kidney  cortex  or  of  the  perinephritic  tissues. 
A  characteristic  of  these  mesotheliomata  is  the  frequency  with  which  they 
involve  the  veins,  the  tumor  tissue  growing  out  into  the  renal  vein  even 
beyond  the  hilum.  Metastasis  is  probably  always  by  the  blood  stream;  the 
organs  most  often  involved  are  the  liver  and  bones.  The  cells  of  the  tumors 
are  polygonal  in  type,  usually  arranged  about  blood-vessels,  sometimes  form- 


670 


GENITO-URINARY  SURGERY 


ing  finger-like  projections,  sometimes  filling  up  alveoli  formed  of  comiective 
tissue.  There  may  be  a  distinct  cordon-formation,  such  as  is  seen  in  the 
adrenal,  or  tubules  may  be  present  (Fig.  357). 

Nephrogenic  mesotheliomata  make  up  about  75  per  cent,  of  the  renal  tu- 
mors coming  to  the  attention  of  the  surgeon. 

Mixed  Tumors. — These  tumors  are  usually  found  in  children  under  five 
years  of  age.  They  are  due  to  inclusions  in  the  developing  kidney  of  cells 
from  the  adjacent  mesothelial  plate  destined  to  form  the  muscles  and  bony 


«    % 


»J^ 


•4  V 


Fig.  357.— Mesothelioma.      (From  the  Laboratory  of  Surgical  Pathology,  Univer- 
sity of  Pennsylvania.) 

Structures  of  the  body  (Fig.  358).  They  are  of  rapid  growth,  usually  symp- 
tomless save  for  the  presence  of  the  tumor  (Fig.  359),  and  by  the  time  they 
are  seen  by  the  surgeon  are  commonly  undergoing  sarcomatous  degenera- 
tion. The  tumors  grow  with  great  rapidity.  Metastasis  occurs  late,  and  takes 
place  through  the  blood  vascular  system. 

Rhabdomyoma. — Tumors  containing  only  voluntary  muscle  are  occasion- 
ally encountered,  but  are  extremely  rare.  Usually  they  are  sarcomatous '  when 
seen.    They  have  been  found  only  in  early  childhood,  before  the  third  year. 

NoNEPiTHELiAL  SoLiD  TuMORS.— The  benign  tumors  of  this  group  are 
lipoma,  fibroma,  angioma,  lymphangioma,  osteoma,  chondroma,  and  myxoma. 
The  last  four  are  very  rare;  none  are  seen  frequently. 


PLATE  XI. 


Mesothelioma. 


RENAL  TUMORS  AND  PARASITES 


671 


Lipoma. — The  great  majority  of  the  lipomata  reported  have  been  of  small 
size,  accidental  inclusions  of  fatty  tissue  beneath  the  capsule  of  the  kidney. 
Formerly  a  considerable  number  of  tumors  were  reported  as  lipomata  which 
were  in  reality  mesotheliomata  of  the  Grawitzian  type.     The  true  lipomata 


Fig.   358. — Mixed  tumor  of  childhood.      (No.   629.     Specimen  in   Department  of 
Surgical  Pathology,  University  of  Pennsylvania.) 

practically  never  reach  sufficient  size  or  cause  sufficient  symptoms  to  call  for 
the  attention  of  the  surgeon. 

Fibroma. — Tumors  composed  entirely  of  fibrous  tissue  have  not  been  de- 
scribed, but  occasional  specimens  have  been  noted  wherein  fibrous  tissue  made 


Fig.   359. — Mixed  tumor  of  kidney  showing  abdominal  distention;  edges  of   liver  and 
tumor  mass  indicated  by  lines  in  skin. 

up  the  bulk  of  myo-  or  myxo-fibromata ;  however,  these  have  never  been  of 
considerable  size.  Small  collections  of  fibrous  tissue  are  probably  the  source 
of  origin  of  many  of  the  true  sarcomata  of  the  kidney. 


672  GENITO-URINARY  SURGERY 

Angioma,  papillary  renal  varix,  or  telangiectasis,  differs  from  the  pre- 
ceding in  the  greater  frequency  of  its  occurrence  and  in  the  production  of  symp- 
toms, sometimes  of  sufficient  gravity  to  threaten  the  patient's  life.  While  they 
are  usually  situated  in  one  or  all  of  the  renal  papillae,  causing  them  to  appear 
greatly  enlarged  and  engorged,  they  may  also  spring  from  the  mucosa  of  the 
pelvis.    The  resultant  hemorrhage  may  be  so  great  as  to  demand  nephrectomy. 

Sarcoma. — Practically  all  the  different  varieties  of  sarcoma  occur  in  the 
kidney.  While  by  no  means  rare,  sarcoma  is  not  as  common  as  the  other 
m.alignant  tumors,  particularly  the  nephrogenic  mesotheliomata,  and  mixed 
tumors  of  childhood,  the  latter  being  generally  considered  as  a  distinct  group, 
though  they  frequently  exhibit  sarcomatous  degeneration.  It  is  a  tumor  of  the 
cortex  of  the  kidney  (Fig.  360),  frequently  originating  in  nodules  of  fibrous 


Hemorrhagic  sarconi' 
atous  growth 


Necrotic  sarcoma- 
tous tissue 


Shell  of  normal 
kidney  tissue 


Fig.  360. — Sarcoma  of  kidney.  CNo.  2128.  Speci- 
men in  Laboratory  of  Surgical  Pathology,  University  of 
Pennsylvania.) 

tissue;  it  is  distinctly  a  tumor  of  adult  life.  Usually  sarcomata  are  encap- 
sulated. The  degree  of  malignancy  depends  upon  the  histological  elements 
present  (Fig.  361),  as  in  sarcomata  elsewhere  in  the  body;  metastasis  is  by 
way  of  the  blood-vessels. 

Epithelial  Solid  Tumors. — Adenoma. — Small  single  or  multiple  adeno- 
mata are  of  rather  frequent  occurrence,  particularly  in  the  contracted  kidney. 
They  must  be  distinguished  from  embryonic  inclusions  and  ectatic  hyperplastic 
formations.  They  spring  from  the  tubular  epithelium;  the  cells  are  cuboidal 
or  cylindrical,  and  the  acini  have  a  well-formed  tunica  propria.  Alveolar, 
tubular,  and  capillary  forms  can  be  differentiated.  Occasionally  an  adenoma 
may  attain  very  large  proportions.  A  special  variety  is  the  cystadenoma,  which 
presents  a  papillary  arrangement.    Adenomata  must  be  regarded  as  potentially 


RENAL  TUMORS  AND  PARASITES  673 

malignant,  their  chief  importance  lying  in  their  tendency  to  undergo  carcinom- 
atous degeneration. 

Papilloma. — This  is  the  commonest  tumor  of  the  renal  pelvis;  it  may 
spring  either  from  the  renal  tissue  or  from  the  pelvic  mucosa.  The  tumors 
may  be  single  or  multiple.  The  histological  characteristics  are  those  of  papil- 
lomata  of  the  mucous  membranes  of  other  parts  of  the  body — numerous  villi 
consisting  of  a  central  blood-vessel  supported  by  Ipose  connective  tissue  cov- 
ered with  several  layers  of  cells. 

Papillomata  tend  to  undergo  carcinomatous  degeneration,  and  also  give 
surface  metastases  to  the  ureter  and  bladder.  They  are  usually  symptomless 
till  hemorrhage  occurs  from  rupture  of  their  blood-vessels,  but  pain  may  be 
produced  by  blockage  of  the  ureter,  or  the  ureteral  orifice  of  the  pelvis.  Such 
an  obstruction  may  cause  hydronephrosis. 


Fig.    361. — Photomicrograph    of    section    from 
sarcoma  of  kidney  shown  in   Fig.   360. 

Carcinoma. — This  develops  from  the  tubular  epithelium,  or  occasionally 
from  the  epithelium  of  the  pelvis.  In  some  cases  the  urinary  canals  may  to 
a  certain  extent  persist,  and  if  dilated  may  form  large  spaces.  The  much- 
discussed  intracellular  formations  of  cancer-cells  ( cocci dia)  are  well  seen  in 
these  growths. 

Cancer  may  be  single  or  multiple,  and  may  attain  tremendous  proportions. 
Two  types  may  be  distinguished:  the  nodular  type,  including  growths  which 
are  adeno-carcinomatous  (adenomatous  at  the  beginning)  and  exhibit  an  alveo- 
lar arrangement,  with  cuboidal  or  cylindrical  cells;  and  the  infiltrating  type, 
including  growths  which  are  cancerous  from  the  beginning  and  show  little 
alveolar  structure;  their  cells  are  polymorphous  (Fig.  362). 

In  the  renal  substance  around  the  growth  a  compensatory  hypertrophy 
may  occur.  More  often  there  is  a  parenchymatous  degeneration  with  inter- 
stitial overgrowth;  at  times  amyloid  degeneration.  The  central  portions  of 
the  growth  often  soften  and  break  down,  forming  cysts  with  sanguinolent 
contents;  this  breaking  down  is  typical  of  carcinoma  rather  than  mesothelioma. 
43 


674 


GENITO-URINARY  SURGERY 


The  pelvis  of  the  kidney  may  be  involved  (Fig.  363),  then  the  walls  of 
the  ureter  and  perhaps  of  the  blood-vessels,  and  later  the  adrenal  and  the 
fatty  capsule;  ultimately  the  infiltration  may  spread  to  the  pancreas  or  the 
intestines. 

Clinically,  the  neoplasm  may  be  hard  or  soft,  more  often  soft;  it  may  be- 
come colloid  and  may  form  a  fungoid  vascular  mass.  It  has  been  found  asso- 
ciated with  testicular  carcinoma  and  (in  the  aged)  with  calculus.  In  a  few 
cases  the  growth  has  broken  through  the  skin.  Metastasis  occurs  most  fre- 
quently to  the  retroperitoneal  lymph-glands,  the  lung,  and  the  liver. 

The  tendency  to  produce  hsematuria  is  due  to  the  infiltration  of  the  tumors. 


%     ^ 


Fig.   362. — Carcinoma  of  the   kidney.      (From   the   Laooratory  of 
Surgical  Pathology,  University  of  Pennsylvania.) 

The  earlier  metastases  occur  through  the  lymphatics;  later,  when  the  veins 
have  been  invaded,   carcinomatous  thrombi  may  be  carried  by  these  vessels. 

Contrary  to  the  formerly  accepted  opinion,  carcinoma  of  the  kidney  is 
rare  before  the  fifth  decade;  the  mistaking  of  mixed  tumors  for  carcinomata 
is  responsible  for  the  large  number  of  these  growths  formerly  reported  as 
occurring  in  extreme  youth. 

Papillary  Cystadenoma,  or  Papilloadenocarcinoma.— »-This  tumor  oc- 
curs wath  about  the  same  frequency  as  other  forms  of  renal  carcinoma.  It 
is  to  be  regarded  as  a  malignant  degeneration  of  the  cystadenoma.    The  dif- 


RENAL  TUMORS  AND  PARASITES 


675 


ferential  diagnosis  from  other  forms  of  carcinoma  is  possible  only  by  the 
microscope  (Fig.  364);  the  papillary  formation,  associated  with  tubular  pro- 
liferation within  cysts  of  variable  size,  is  characteristic. 

Symptoms  of  Benign  Tumors. — With  the  exception  of  those  tumors  which 
involve  the  pelvis  of  the  kidney,  the  majority  of  benign  growths  cause  no 
symptoms  and  either  escape  recognition  or  are  discovered  accidentally.  Occa- 
sionally the  size  of  a  benign  tumor  leads  to  its  detection.  Those  tumors 
which  affect  the  pelvis  frequently  cause  more  or  less  haematuria. 

Symptoms  of  Malignant  Tumors. — The  three  chief  symptoms,  in  order 
of  their  observation  by  the  patient,  are  pain,  haematuria,  and  tumor.  All 
three  symptoms  may  be  present  in  an  individual  case,  or  one  or  two  of  them 


Fig.  363. — Carcinoma  of  the  kidney.  Growth  is  seen  to  infiltrate 
the  pelvis.  (From  Laboratory  of  Surgical  Pathology,  University  of  Penn- 
sylvania.) 

may  be  absent,  making  the  diagnosis  more  difficult.  In  a  series  of  83  cases 
operated  upon  in  the  Mayo  Clinic  and  reported  by  Braasch,  all  three  symp- 
toms were  present  in  32  cases,  two  of  the  three  in  37  cases,  and  but  one 
symptom  in  14  cases.  Pain  was  complained  of  by  82  per  cent,  of  the  patients, 
and  was  the  first  symptom  in  32  per  cent.;  haematuria,  observed  by  64  per 
cent,  of  the  patients,  was  the  first  symptom  in  47  per  cent.;  while  tumor 
was  the  first  evidence  of  disease  in  IS  per  cent,  of  cases,  was  known  to  be 
present  by  34  per  cent,  of  the  patients,  and  was  found  by  clinical  examination 
in  78  per  cent. 

Pain  is  very  variable  in  its  intensity  and  distribution.  When  due  to 
distention  of  the  renal  capsule  it  is  usually  limited  to  the  region  of  the  kid- 
ney, but  when  due  to  pressure  on  the  nerve-trunks  and  surrounding  organs  its 


676 


GENITO-URINARY  SURGERY 


distribution  may  be  very  wide— throughout  the  abdomen,  to  both  kidneys,  to 
the  back,  as  in  gall-bladder  disease,  or  to  the  genitalia. 

To  be  of  clinical  value,  hgematuria  must  be  so  marked  as  to  be  detected 
by  the  unaided  eye.  It  is  usually  an  intermittent  symptom.  So  much  blood 
may  be  present  that  the  clots  are  the  cause  of  ureteral  colic. 

When  a  tumor  is  palpable  it  may  be  evidently  a  growth  of  the  kidney, 
or  it  may  appear  as  a  mass  of  doubtful  origin.  The  tumor  is  often  adherent 
to  the  posterior  abdominal  wall,  the  small  intestines  are  pushed  to  one  side, 
and  the  colon  lies  upon  the  growth.  As  a  rule,  there  is  no  movement  upon 
respiration,  though  this  is  occasionally  observed  in  cases  of  tumor  of  the 
right  kidney.  The  feel  of  the  tumor  is  hard,  and  may  be  smooth  or  nodular. 
Exceptionally  there  may  be  pulsation  and  a  vascular  murmur.     If  the  colon 


Fig.      364.^Papilloadenocarcinoma.       Note    the     papillary  ' 
formation  and  tubular  proliferations  within  a  cyst.     (From  a  case  of 
Dr.  G.  E.  Shoemaker,  The  Journal  of  American  Medical  Association.) 

is  alternately  filled  with  air  and  emptied,  percussion  will  show  that  the  tumor 
lies  behind  this  segment  of  the  intestine.  The  spleen  is  displaced  by  a  tumor 
of  the  left  kidney,  and  when  the  growth  attains  large  dimensions  various 
transpositions  of  the  organs  may  be  seen. 

If  one  hand  be  laid  upon  the  abdomen  and  the  lumbar  region  gently 
tapped  with  the  other  hand,  Guyon's  sign  may  be  elicited  {ballottement  renal), 
a  sign  never  produced  by  a  normal  kidney. 

Pus  may  be  found  in  the  urine,  but  not  in  a  sufficiently  large  percentage 
of  cases  to  be  of  diagnostic  value.  Occasionally  tumor  tissue  is  separated  from 
the  main  mass  and  escaDes  by  way  of  the  urethra. 

Marked  dilatation  of  the  superficial  blood-vessels  has  been  noted  frequently 
in  patients  suffering  from  hypernephroma  (Braasch).     The  face,  the  scrotum 


RENAL  TUxMORS  AND  PARASITES  677 

(varicocele),  and  the  bladder  are  the  most  frequent  places  where  this  is 
observed.  The  development  of  a  varicocele  late  in  life  suggests  examination 
for  a  renal  tumor. 

There  are  gastric  and  intestinal  symptoms  (indigestion  and  constipation), 
with  occasional  diarrhoea.  Ascites  is  often  present  in  the  late  stages.  Pressure 
upon  the  iliac  veins  or  the  inferior  vena  cava  may  cause  a  more  or  less  pro- 
nounced oedema  of  the  legs,  while  severe  neuralgia  with  paresis  may  result  from 
pressure  upon  the  nerves.  In  late  stages  the  inguinal  nodes  may  become 
enlarged.    The  constitutional  symptoms  may  remain  long  in  abeyance. 

Sooner  or  later  the  patient  becomes  anaemic,  and  a  marked  cachexia  finally 
develops  with  mental  derangement  and  an  irregular  fever,  due  probably  to 
uraemia  or  auto-intoxication.  Symptoms  of  metastasis  may  appear.  In  some 
cases  a  high  pulse-rate  is  maintained.  Kiihn  has  pointed  out  that  in  children 
with  congenital  mixed  tumors  there  is  often  a  "precocious  development  of  the 
pubic  and  axillary  hair  and  of  the  cutaneous  pigment. 

DL4GN0SIS. — ^The  diagnosis  is  founded  upon  pain,  profuse  intermittent 
renal  hemorrhage,  the  development  of  a  kidney  tumor  which  is  steadily  pro- 
gressive, the  passage  of  fragments  of  neoplasm,  the  cystoscopic  appearance,  the 
result  of  functional  renal  tests,  and  pyelography. 

In  the  early  stages  of  tumor  the  diagnosis  is  obscure,  and  the  condition 
may  be  confoimded  with  renal  tuberculosis  and  calculous  pyelitis.  WTien, 
however,  the  growth  becomes  palpable,  the  fact  that  it  can  be  felt  by  lumbar 
palpation  or  can  be  so  pushed  forward  by  pressure  from  behind  that  abdom- 
inal palpation  becomes  much  easier,  is  highly  characteristic  of  renal  tumor. 

Cancer  of  the  colon  may  closely  simulate  renal  neoplasm;  auscultatory 
percussion  may  aid  in  distinguishing  between  these  two  affections.  Moreover, 
primary  involvement  of  the  colon  is  more  commonly  complicated  by  partial 
or  complete  intestinal  obstruction  and  by  the  passage  of  blood-stained  faeces 
without  haematuria.  Kidney  neoplasm  rarely  infiltrates  the  colon.  The  lateral 
position  of  renal  tumors  and  the  lumbar  bulge  is  in  contrast  to  the  central 
position  of  growths  arising  from  retroperitoneal  lymph-nodes. 

Pancreatic  cysts  can  scarcely  be  distinguished  from  renal  enlargements. 
Minkowsky's  method  of  colonic  distention  with  liquid  may  prove  serviceable 
in  differentiating  between  the  two  affections.  When  the  colon  is  filled  with 
water  the  kidney  tumor  is  thrust  back  into  the  lumbar  region. 

Tumors  of  the  suprarenal  capsule  do  not  often  reach  great  size.  Dif- 
ferential diagnosis  between  these  tumors  and  those  of  the  kidney  is  impossible. 

From  large  pelvic  tumors  renal  growths  may  sometimes  be  distinguished 
by  the  fact  that  if  the  patient  be  placed  in  the  Trendelenburg  position  there 
may  be  demonstrated  a  tympanitic  area  between  the  pelvis  and  the  lower 
border  of  the  kidney  tumor. 

The  intermittent,  profuse,  apparently  causeless  bleeding  of  renal  neoplasm 
is  simulated  only  by  suppurative  nephritis,  purpura,  and  haemophilia.  Other 
symptoms  of  these  conditions  will  suggest  their  presence.  Bleeding  from  renal 
calculus  is  usually  excited  by  exercise  or  jarring,  and  is  promptly  and  favor- 
ably influenced  by  rest;  it  is  not  often  sufficiently  pronounced  to  cause  clots. 
Bleeding  from  a  tuberculous  kidney  is  usually  slight,   but  may  be  severe. 


678  GENITO-URINARY  SURGERY 

The  presence  of   tubercle  bacilli   is  sometimes   the   only  possible  means   of 
making  a  differential  diagnosis. 

The  superficial  veins  of  the  bladder  are  sometimes  so  markedly  distended 
in  patients  with  renal  neoplasms,  especially  hypernephromata,   as  to  suggest 


Fig.  365. — Colloidal  silver  injection  shows  renal  pelvis  to  be  constricted,  its 
calyces  either  irregularly  distended  or  elongated  and  narrowed.  Diagnosis:  mesothelioma. 
Confirmed  at  operation.     (Mayo's  Clinics,  W.  B.  Saunders  Co.) 

the  diagnosis.  A  reduction  of  the  functional  power  of  the  kidney  as.  indi- 
cated by  one  of  the  functional  tests  is  often  helpful  in  distinguishing  between 
renal  and  pararenal  growths. 


RENAL  TUMORS  AND  PARASITES  679 

In  cases  in  which  the  diagnosis  cannot  otherwise  be  estabUshed,  pyelography 
should  be  used.  The  distortion  of  the  pelvis  by  a  renal  tumor  is  often  quite 
characteristic.  "  Spider-leg  "  retraction  is  most  often  seen,  the  narrowed  calyces 
extending  abnormally  far  into  the  substance  of  the  kidney.  Other  frequent 
findings  are  narrowing  of  the  pelvis  (Fig.  365),  irregular  pelvic  dilatation  on 
account  of  tumor  necrosis,  and  abnormal  position  of  the  pelvis — too  near  or 
too  far  from  the  median  line  of  the  body. 

It  is  not  possible  to  differentiate  between  the  various  malignant  growths. 

Prognosis. — Without  operation  the  ultimate  outcome  of  malignant  disease , 
of  the  kidney  is  inevitably  fatal,  the  average  length  of  life   from  the  onset 
of  symptoms  being  about  three  or  four  years;   death  results  from  hemorrhage, 
renal  insufficiency,  asthenia,  or  from  metastases  in  vital  organs. 

The  mortality  of  operation  is  from  ten  to  fifteen  per  cent.  The  pros- 
pect of  permanent  cure  after  removal  of  the  tumor  depends  largely  upon  the 
date  at  which  operation  is  performed.  Braasch  found  that  those  patients 
operated  upon  in  the  Mayo  Clinic  who  were  reported  as  well  at  the  end  of 
three  years  had  had  symptoms  for  an  average  period  of  1.6  years  when  they 
applied  for  treatment,  while  of  those  who  lived  less  than  three  years  the 
duration  of  symptoms  was  2.8  years. 

Treatment. — For  those  cases  which  are  seen  before  the  disease  has  spread 
beyond  the  confines  of  the  kidney,  the  only  treatment  to  be  considered  is 
nephrectomy.  In  the  presence  of  metastases,  of  a  tumor  firmly  fixed  to  the 
surrounding  structures,  of  marked  ascites,  or  great  emaciation,  the  disease  being 
irremovable,  the  symptoms  must  be  treated  as  they  arise.  However,  when 
any  hope  whatever  of  complete  removal  exists,  even  with  some  risk  to  life, 
the  patient  should  be  given  the  advantage  of  operative  treatment. 

The  incision  must  be  free,  running  from  the  lumbar  muscles  just  below 
the  last  rib  to  the  middle  of  the  rectus  on  the  same  side.  The  rib  should 
be  freed  or  resected  and  the  kidney  removed  with  the  perinephric  fat,  if  this 
be  possible. 

Cystic  Tumors. — Simple  Cysts. — These  are  of  two  kinds:  small,  usually 
multiple,  retention  cysts,  and  large  serous  cysts,  usually  single. 

Retention  Cysts. — These  cysts,  varying  in  diameter  from  a  millimetre  to 
a  centimetre,  are  probably  caused  by  blocking  of  the  secreting  tubules.  They 
cause  no  symptoms,  demand  no  treatment,  and  are  of  importance  only  through 
danger  of  their  being  mistaken  for  polycystic  degeneration. 

Serous  Cysts. — Possibly  of  similar  origin  as  the  foregoing,  possibly  due  to 
the  development  of  embryonic  rests,  serous  cysts  arise  usually  from  the  lower 
pole  of  the  kidney,  more  often  in  women  than  in  men.  Though  usually  of 
moderate  size,  occasionally  they  reach  enormous  proportions,  Morris  having 
reported  one  whose  content  weighed  16  pounds.     The  condition  is  rare. 

When  small  they  produce  no  symptoms  and  demand  no  treatment;  when 
•  of  large  size  they  may  cause  pain  by  pressure.  The  larger  tumors  have  been 
mistaken  for  ovarian  cysts;  a  more  frequent  error  is  to  mistake  them  for  cases 
of  hydronephrosis.  Drainage  of  the  cyst  cavity  after  carbolization,  resection 
of  the  cyst-wall,  and  nephrectomy  are  the  methods  of  treatment  which  have 
been  employed;  when  the  opposite  kidney  is  functionally  sufficient  the  last 
method  is  the  one  to  be  preferred. 


680 


GENITO-URINARY  SURGERY 


Polycystic  Degeneration. — In  this  condition  the  kidney,  almost  invariably 
both  kidneys,  is  converted  into  a  mass  of  cysts  (Fig.  366),  with  comparatively 
little  unchanged  renal  tissue  between  the  vesicles.  The  cysts  are  usually  of 
small  size,  though  occasionally  one  of  the  cysts  may  become  larger  than  its 
fellows,  even  growing  to  the  size  of  a  grape-fruit.  The  etiology  of  the  condi- 
tion is  not  known,  nor  is  it  known  whether  the  infantile  and  adult  forms 
of  the  disease  have  the  same  derivation.  The  disease  is  most  common  during 
the  first  and  after  the  fortieth  year  of  life;  it  is  almost  unknown  between  the 
first  and  twenty-first  years.  It  may  develop  during  intra-uterine  life,  and 
be  so  far  advanced  at  the  time  of  birth  as  to  cause  dystocia. 


Fig.  366. — Polycystic  degeneration  of  kidney. 
(No.  3363.  Specimen  in  the  Laboratory  of  Surgical 
Pathology,   University  of  Pennsylvania.) 

Symptoms. — Pain  in  the  loin,  due  to  distention  of  the  renal  capsule,  or 
that  of  ureteral  colic,  due  to  the  passage  of  clots  of  blood,  haematuria,  and  the 
evidences  of  a  failing  renal  function,  together  with  the  presence  of  a  steadily 
growing  tumor  (or  tumors,  as  the  disease  is  bilateral  in  almost  every  case), 
are  the  signs  of  polycystic  disease  of  the  kidneys.  In  the  infant,  death  usually 
occurs  within  a  few  months;  in  the  adult,  the  onset  of  the  disease  may  be 
insidious,  and  the  course  may  extend  over  a  number  of  years. 

The  diagnosis  is  made  by  the  discovery  of  bilateral  nodular  renal  tumors, 
there  being  no  source  from  which  metastatic  tumors  might  have  arisen,  at  a 
period  of  life  at  which  these  growths  are  commonly  found.  When  doubt 
exists  as  to  the  character  of  the  tumor,  pyelography  is  usually  a  reliable  means 


RENAL  TUMORS  AND  PARASITES  681 

of  differentiation,  the  "spider-leg"  appearance  found  in  the  case  of  soHd 
tumor  never  being  seen;  instead,  the  calyces  are  apt  to  be  obliterated,  giving 
the  pelvis  an  oval  or  squared  contour,  or,  if  the  calyces  be  retracted,  they  ap- 
pear as  broad  spaces. 

Treatment. — On  account  of  the  almost  uniformly  bilateral  character  of 
the  disease  nephrectomy  is  rarely  permissible,  and  both  kidneys  should  al- 
ways be  exposed  before  one  cyst-studded  organ  is  removed.  Occasionally 
pain  can  be  relieved  by  the  simple  evacuation  of  cysts  of  large  size.  Other- 
wise treatment  is  entirely  symptomatic. 

Dermoid  Cysts. — These  extremely  rare  tumors  are  similar  in  character 
to  dermoid  cysts  in  other  parts  of  the  body.  Diagnosis  can  only  be  made  by 
section  of  the  cyst.     Nephrectomy  is  the  treatment  indicated. 

Echinococcus  cysts  are  considered  under  "Parasites  of  the  Kidney" 
(see  below). 

Paranephric  Tumors. — These  may  be  cystic  or  solid;  both  are  of  rare  oc- 
currence. The  cysts,  unilateral  and  unilocular,  are  usually  encapsulations 
of  haematomata;  most  of  the  others  are  due  to  the  development  of  embryonic 
rests.  They  are  symptomless  save  for  their  bulk,  which  is  sometimes  great. 
The  treatment  is  excision;  this  is  easy  in  the  case  of  the  smaller  cysts,  but 
removal  of  the  larger  growths  is  sometimes  a  perilous  procedure.  With  the 
exception  of  sarcomatous  degenerations,  pararenal  cysts  .are  benign. 

Solid  pararenal  tumors  spring  from  the  fibrous  and  fatty  perirenal  struc- 
tures. With  the  exception  of  sarcomata,  which  are  occasionally  seen,  they 
grow  slowly  and  are  readily  removed. 

PARASITES    OF    THE    KIDNEY 

Echinococcus  (Hydatid)  Cysts. — The  kidney  is  affected  only  in  from 
five  to  eight  per  cent,  of  all  cases  of  hydatid  disease,  and  the  process  is  gen- 
erally confined  to  one  kidney  (usually  the  left).  Any  part  of  the  gland  may 
be  affected,  but  the  primary  cyst  forms  in  the  cortex.  The  arrangement  is 
that  of  the  echinococcus  hydatidosus.  The  cysts  may  become  very  large 
(eight  inches  in  diameter),  but  are  usually  the  size  of  an  orange;  they  exhibit 
a  tendency  to  protrude  into  the  abdominal  cavity,  may  contract  adhesions  to 
the  abdominal  walls  and  to  the  viscera,  and  may  rupture  into  the  pelvis,  ureter, 
intestines,  stomach,  pleura,  or  bronchi,  rarely  into  the  peritoneum  or  through 
the  lumbar  muscles.  Suppuration  may  occur  spontaneously  in  the  unruptured 
cyst  or  may  be  provoked  by  traumatism;  septic  absorption  usually  follows, 
and  general  pyaemia  results.  The  contents  of  the  cyst  are  slightly  albuminous 
or  mucoid  and  contain  the  booklets.  Hydatid  cysts  may  coexist  in  other 
parts  of  the  body. 

Symptoms. — ^There  is  very  little  acute  pain  in  connection  with  hydatid 
renal  disease;  there  is  often  a  sense  of  discomfort  and  of  dragging;  finally, 
pressure-pains  develop,  but  not  until  the  disease  is  over  a  year  old.  Wheri^ 
however,  the  cyst  ruptures  into  the  pelvis  a  ureteral  colic  is  provoked,  with 
very  severe  paroxysms  of  pain;  the  ureter  may  be  plugged  by  tissue  or  by  a 
daughter  cyst,  with  temporary  or  permanent  hydronephrosis.  In  a  few  cases 
a  general  urticaria  has  followed  the  evacuation  of  the  cyst. 


582  GENITO-URINARY  SURGERY 

In  the  event  of  a  rupture  positive  diagnosis  may  be  made  by  urinalysis. 
After  rupture  the  cyst  may  become  infected  and  suppurate,  with  the  pro- 
duction of  a  pyonephrosis.  In  a  few  cases  direct  symptoms  have  been  excited 
by  pressure  upon  veins.  Frequent  urination  was  the  chief  symptom  in  a  case 
of  Tait's. 

The  tumor  is  round,  and  may  be  tender  on  pressure;  it  may  feel  hard 
or  may  fluctuate  distinctly;  the  hydatid  thrill  is  rarely  elicited  in  renal  cysts. 
An  eosinophilia  may  be  present. 

Diagnosis. — Hydatid  cysts  are  ordinarily  to  be  confused  only  with  hydro- 
nephrosis or  ovarian  cysts. 

Treatment. — Recovery  after  spontaneous  evacuation  is  very  rare.  The 
only  treatment  to  be  considered  is  operative.  The  cyst  is  exposed,  aspirated, 
and  injected  with  a  five  per  cent,  formaldehyde  solution,  and  a  few  minutes 
later  dissected  free  from  its  fibrous  investment.  The  resultant  cavity  is  closed 
by  suture.     For  a  suppurating  cyst,  drainage  is  indicated. 

Strongylus  gigas,  or  "palisade  worm,"  is  a  parasite  of  animals,  the  pres- 
ence of  which  in  the  kidney  of  man  is  doubted. 

Distoma  haematobium  is  a  parasite  observed  among  the  Fellahs  and  Copts. 
The  worm  lives  in  the  portal  vein  and  its  branches.  The  eggs  are  found  in 
the  capillaries  of  the  mucous  membrane  of  the  urinary  tract.  Diagnosis  is 
based  on  finding  the  eggs  or  embryos. 

Pentastoma  denticulatum  has  been  found  on  post-mortem  examination 
in  the  kidney  of  man. 

Spiroptera  hominis  and  Dactylius  aculeatus  have  been  found  by  Rayer 
in  the  urine.  (For  detailed  description  of  these  parasites,  see  Leuckart,  "Die 
thierische  Parasiten.") 


CHAPTER  XXXII 

SURGERY  OF  THE  SUPRARENAL  GLANDS 

The  suprarenal  glands  are  of  interest  to  the  genito-urinary  surgeon  for  two 
reasons,  first  beause  these  organs  seem  to  have  some  relationship  to  sexual 
development,  and  secondly  because  their  enlargements  are  likely  to  be  confused 
with  renal  growths. 

Each  gland  consists  of  a  medulla  and  cortex,  the  two  being  derived  from 
entirely  different  fundaments,  and  having  entirely  different  functions.  The 
medulla,  in  part  or  wholly,  is  derived  from  the  fundament  of  the  sympathetic 
ganglia,  and  is  a  part  of  the  so-called  chromaffin  system;  it  is  undetermined 
whether  the  whole  medulla  is  of  S3anpathetic  derivation,  or  whether  a  part  arises 
from  cortical  cells.  The  chief  or  only  function  of  the  medulla  seems  to  have 
to  do  with  the  maintenance  of  blood  pressure.  The  suprarenal  cortex  is  derived 
from  the  anterior  portion  of  the  Wolffian  ridge  from  which  the  kidney  and 
genital  gland  likewise  spring.  Our  knowledge  of  its  function  is  not  complete, 
but  it  certainly  concerns  sexual  development. 

The  suprarenals  are  somewhat  flattened  organs,  lying  above  and  to  the  inner 
side  of  the  kidneys.  Their  enveloping  capsules  are  less  strong  than  those  of 
the  kidneys,  so  that  there  is  a  greater  tendency  for  tumors  of  these  organs  to 
invade  the  surrounding  tissues.  Their  blood  supply  comes  in  part  direct  from 
the  aorta,  in  part  by  way  of  the  renal  artery,  and  in  part  by  a  branch  of  the 
phrenic.  The  lymph  vessels  empty  into  the  receptaculum  chyli.  The  organs 
are  firmly  secured  in  their  positions,  so  that  displacement  is  rare. 

TUBERCULOSIS 

This  is  probably  the  commonest  affection  of  these  glands,  and  is  usually 
secondary  to  tuberculosis  elsewhere  in  the  body.  It  may  be  unilateral  or  bi- 
lateral, and  may  be  accompanied  by  the  bronzed  skin  of  Addison's  disease. 
In  addition  to  this  there  are  very  marked  wasting  and  distressing  gastric  dis- 
turbances, with  haematemesis.  The  symptoms  of  a  secondary  anaemia  are  pres- 
ent.    Slight  tenderness  may  be  elicited. 

Tuberculosis  has  usually  been  considered  a  medical  condition,  but  a  few 
cases  have  been  successfully  operated  upon. 

ABSCESS 

Traumatism,  tuberculosis,  septicaemia,  or  pyaemia  may  be  responsible  for  this 
condition.  The  diagnosis  is  founded  on  the  history  of  the  case,  the  localizing 
signs  in  the  epigastrium  and  lumbar  region,  and  the  symptoms  of  sepsis.  Ex- 
ploration with  retroperitoneal  incision  of  the  abscess  is  the  treatment  indi- 
cated. 

683 


584  GENITO-URINARY  SURGERY 

SUPRARENAL  TUMORS 

Neoplasms  of  the  suprarenals  have  been  observed  so  seldom  that  neither 
their  symptomatology  nor  their  histological  characteristics  are  fully  under- 
stood. The  most  comprehensive  article  on  the  subject  is  that  of  Glynn.- 
The  tumors  may  be  either  benign  or  malignant,  and  may  involve  either  the 
medulla  or  the  cortex.    Glynn  gives  the  following  classification: 

Benign  Tumors 

A.  Medullary  tumors:  Group  1. — Hyperplasia  (Clinically  accompanied  by  high 

blood-pressure) . 
Group  2. — Glioma,  Ganglion  neuroma. 

B.  Cortical  tumors:   Group  1. — Diffuse  hyperplasia. 
Group  2. — Adenomata  (strumarenalis  of  Virchow). 

Malignant  Tumors 

A.  Medullary  tumors:   Group  1. — Gliosarcoma  (very  rare). 

Group  2. — Sarcoma.     Six  cases  have  been  reported,  marked  clinically  by 
high  blood-pressure. 

B.  Cortical  tumors:  Group  1. — Sarcoma,  often  lymphosarcoma.    The  tumor  is 

common  in  male  children,  especially  between  two  and  three  years  of 
age.     Metastasis  is  most   often  to  the  liver,  lungs,   ribs,   and   cranial 
bones.     Exophthalmos  from  the  last  form  of  metastasis  is  sometimes 
seen. 
Group  2. — Hypernephroma  or  mesothelioma.     This  has  the  following  struc- 
ture:   "It  is  a  growth  whose  general  appearance  recalls  in   a  greater 
or  less  degree  the  adrenal  cortex.     It  consists  mainly  of  round,  oval,  or 
polyhedral — but  never  cylindrical — epithelial-like  cells,  usually  varying 
considerably  in  shape   and   size;    sometimes  multinucleated   giant-cells 
are  present.     Unless  the  anaplasia  is  great,  the  cells  are  separated  into 
alveoli  or  columns  by  a  varying  amount  of  delicate  connective-tissue 
stroma,  or  of  thin-vv^alled  blood-vessels  upon  whose  walls  they  directly 
abut  (Fig.  367);   they  are  sometimes  arranged  in  a  perivascular  man- 
ner.    The  general  arrangement  of  the  cells,  connective  tissue,  and  ves- 
sels suggests  more  or  less  completely  the  zona  fasciculata,  and  the  growth 
is  of  a  carcinomatous  type.     In  other  tumors,  or  even  in  other  parts 
of  the  same  tumor,  the  cells  are  more  spindle-shaped,  and  the  general 
appearance  is  that  of  a  sarcoma  of  a  mixed-celled  or  large  round-celled 
type  with  many  giant-cells.     It  may  be  very  vascular." 
Gastro-intestinal  symptoms  are  usually  prominent,  as  is  loss  of  flesh  and 
strength.     Pain,  felt  at  the  site  of  the  tumor,  or  across  the  abdomen,  or  in 
the  shoulder,  is  complained  of  early.     The  tumor  is  felt  first  at  the  end  of 
the  seventh  or  eighth  costal  cartilage,  rather  higher  than  tumors  of  the  kid- 
neys; it  may  reach  the  size  of  two  fists.     However,  the  most  interesting  class 
of  symptoms  are  observed  in  children.    These  were  found  by  Glynn  to  be  of 
two  types.     In  the  obese  type,  found  in  both  sexes,  there  were  no  genital 

'Quarterly  Journal  of  Medicine,  1912,  v,  pp.   157-192. 


SURGERY  OF  THE  SUPRARENAL  GLANDS 


685 


symptoms  save  an  overgrowth  of  hair,  both  on  the  pubis  and  on  other  parts 
of  the  body.  In  the  second  type  there  was  a  marked  sexual  precocity  among 
the  males,  and  an  unusual  muscular  development.  It  was  observed  that  hyper- 
nephromata  are  associated  with  sexual  abnormalities  almost  invariably  in  chil- 
dren, usually  in  adult  females  before  the  menopause,  but  apparently  never  in 
adult  females  after  the  menopause,  or  in  adult  males.  In  general,  the  influence 
of  an  overacting  adrenal  cortex  seemed  to  be  to  accentuate  masculine  char- 


'■3'^-^^^fe;^;^r?5^^?^'^%^ 


-S'iS- 


Fig.  367. — Hypernephroma  of  suprarenal 
gland.  (From  the  Laboratory  of  Surgical 
Pathology,  University  of  Pennsylvania.) 

acteristics  in  males,  and  in  females  to  cause  the  development  of  masculine 
qualities.  The  opposite  tendency  has  been  noted  but  rarely.  Adrenal  rests 
or  bilateral  hyperplasia  of  the  adrenal  glands  are  found  in  at  least  15  per 
cent,  of  female,  but  only  in  0.7  per  cent,  of  male  pseudohermaphrodites. 
Bronzing  of  the  skin  is  a  comparatively  rare  symptom,  even  when  the  disease 
is  bilateral.     Haematuria  is  very  rare. 

Treatment. — When  discovered  before  the  disease  has  formed  metastases 
or  invaded  the  surrounding  structures,  unilateral  tumors  may  be  excised.    The 


686  GENITO-URINARY  SURGERY 

operation  is  often  difficult  on  account  of  adhesions.  As  the  kidney  may  have  to 
be  sacrificed,  the  function  of  the  opposite  organ  should  always  be  ascertained 
before  operation. 

SUPRARENAL  CYSTS 

These  are  of  surgical  interest  because  they  occasionally  reach  sufficient 
size  to  demand  removal.  True  glandular  cysts  are  not  only  extremely  rare, 
but  seldom  attain  considerable  size,  hence  are  not  of  great  clinical  importance. 
Cysts  of  embryonal  origin  due  to  the  intra-glandular  inclusion  of  Wolffian  debris 
also  arouse  scientific  rather  than  clinical  interest. 

Cystic  adenomata  are  somewhat  more  frequent  than  glandular  cysts,  but 
are  of  very  small  volume  and  diagnosed  only  post  mortem. 

Serous  cysts,  or  cystic  lymphangiomata,  are  commoner  than  the  glandular 
cyst  and  attain  considerable  size.  It  is  probable  that  some  of  these  serous  cysts 
become  hemorrhagic. 

Pseudo  cysts  may  have  for  their  origin  hemorrhage  and  necrobiosis  of  either 
the  normal  or  diseased  suprarenal  gland.  Hemorrhages  may  be  due  to  trauma- 
tism or  may  occur  in  the  course  of  infectious  diseases  (leukaemia,  diabetes,  and 
nephritis)  or  intoxications.  These  cysts  are  always  unilateral,  hence  do  not 
give  rise  to  the  symptoms  of  Addison's  disease.  Symptoms  are  varying  and 
the  diagnosis  almost  impossible  (Terrier  and  Lecene). 

The  tumor  grows  very  slowly  (years)  in  the  hypochondriac  region,  is 
thoraco-abdominal  in  its  development,  and  becomes  prominent  beneath  the 
costal  margin  to  the  right  or  left.  Even  after  operation  the  origin  of  the  cyst 
may  be  left  in  incertitude. 

The  treatment  consists  either  in  marsupialization  or  complete  extirpation, 
depending  upon  the  extent  and  closeness  of  adhesion. 


CHAPTER   XXXIII 

SYPHILIS 

Syphilis  is  a  contagious,  inoculable  disease;  it  is  also  transmissible  by 
heredity.  The  first  lesion  of  the  acquired  form  of  syphihs  is  a  chancre;  this 
is  followed  by  general  lymphatic  enlargement,  by  eruptions  of  the  skin,  usually 
superficial  and  symmetrical  and  associated  with  similar  lesions  of  the  mucous 
membranes;  later  by  chronic  inflammation  and  infiltration  of  the  cellulo-vascu- 
lar  tissues,  the  bones,  and  the  periosteum,  and  finally  by  the  formation  of 
small  tumors  called  gummata,  which  may  appear  in  any  portion  of  the  body, 
but  which  commonly  develop  in  the  connective  tissue. 

Etiology. — S3^hilis  is  due  to  the  presence  in  the  system  of  the  Treponema 
pallidum  {Spirochoota  pallida)}  The  languor,  pain,  and  fever  preceding  the 
eruption  are  due  to  the  toxines  engendered  by  the  germs  which  are  not  yet 
sufficiently  numerous  and  generalized  to  produce  more  pronounced  symptoms. 
The  eruptions  on  the  skin  and  mucous  membranes  are  due  to  local  lodgement 
and  growth  of  the  infection.  The  profound  alteration  in  nutrition  so  often 
associated  with  the  secondary  eruption  is  a  manifestation  of  the  general  in- 
fection. 

Following  the  secondary  stage  of  the  disease  there  may  be  no  further 
symptoms  of  syphihs,  or,  after  a  period  of  latency,  gummata  may  develop. 
During  this  period  of  untreated  latency  or  apparent  cure,  syphilis  may  be 
transmitted  to  offspring,  showing  the  persistence  of  infection.  Even  a  latent 
infection,  however,  absolutely  protects  against  fresh  inoculation.  A  person 
who  has  syphilis  is  immune  against  a  fresh  attack  till  entirely  rid  of  his 
infection. 

The  majority  of  reinfections  found  in  medical  literature  are  cases  of  so- 
called  relapsing  chancre,  in  reality  a  tertiary  lesion  of  syphilis. 

Immunity  against  Syphilis. — As  a  rule,  it  is  found  impossible  to  inocu- 
late the  syphilitic  virus: 

1.  Upon  a  person  who  has  already  suffered  from  the  acquired  form  of  the 
.  disease,  because  the  infection  persists. 

2.  Upon  a  person  who  has  inherited  syphilis  (Profeta's  immunity). 

3.  Upon  a  mother  who  has  borne  a  syphilitic  child  without  showing  in  her 
own  person  any  of  the  lesions  of  acquired  sj^Dhilis  (Colles's  immunity),  because 
the  mother  is  already  infected. 

Syphilitic  Reinfection. — Although  syphilitic  reinfection  is  rare,  it  un- 
questionably occurs,  more  frequently  of  late  than  formerly,  suggesting  that  a 
greater  number  of  infected  persons  are  cured  by  modern  treatment.  A  re- 
infection can  be  regarded  as  proved  only  when  a  sore  shown  to  be  syphilitic 
by  finding  spirochsetes,  or  a  typical  chancre  followed  by  a  secondary  eruption, 
the  blood  giving  a  strong  Wassermann  reaction,  the  lesions  being  cured  by  spe- 

'  For  further  description  of  this  organism,  see  Chapter  XLIII. 

687 


688  GENITO-URINARY  SURGERY 

cific  treatment  (or  possibly  healing  spontaneously),  recurs  after  a  Wassermann- 
negative  period  of  months  or  years,  the  characteristic  amnesis  being  given. 

The  pseudo-chancre  is  a  relapsing  primary  or  secondary  lesion  or  a 
gumma. 

The  Contagion  of  Syphilis. — ^The  blood  of  a  syphilitic  during  the  second- 
ary period  and  the  secretions  from  syphilitic  lesions  are  contagious.;  however, 
the  number  of  organisms  in  the  secretions  of  gummata  is  so  small  that  the 
danger  of  transmission  of  the  disease  by  this  means  is  almost  infinitely  remote. 
The  blood  may  carry  contagion  after  all  the  visible  lesions  of  S3T)hilis  have 
disappeared. 

Even  during  the  most  active  stages  of  the  disease  the  normal  secretions  are 
usually  not  contagious;  however,  successful  inoculations  have  been  performed 
with  semen  and  milk  of  syphilitics,  and  spirochaetes  have  been  found  in  the 
urine  of  sj^Dhilitic  nephritis. 

It  is  possible  that  in  the  passage  of  the  serum  of  the  blood  through  the 
glandular  membranes  and  cells  the  contagious  particles  are  strained  out. 

The  semen  almost  certainly  during  an  untreated  secondary  period,  and 
exceptionally  during  the  tertiary,  infects  the  embryo,  and,  by  this  means, 
the  organism  of  the  mother. 

After  the  primary  and  secondary  stages  of  the  disease,  both  the  blood 
and  the  discharge  from  the  lesions  are  practically  innocuous,  so  far  as  the 
conveyance  of  syphilis  is  concerned.  This  condition  is  generally  reached  at 
the  end  of  two  years.  After  three  years  contagion  is  rare,  except  by  seminal 
transmission,  and,  according  to  Hutchinson,  there  is  no  recorded  instance  of 
its  having  taken  place  after  five  years.  Nevertheless,  inflammatory  lesions  the 
result  of  s^-philitic  infection  may  appear  for  many  years,  and  inoculation  with 
the  scrapings  of  unbroken  gummata  will  cause  the  development  of  chancre  in 
the  orang-outang  in  more  than  half  the  experiments. 

WTiether  contagion  be  derived  from  the  discharge  of  a  chancre,  from  that 
of  a  mucous  patch,  or  from  the  blood  of  a  syphilitic,  the  primary  lesion  at 
the  seat  of  inoculation  is  a  chancre.  Except  in  the  hereditary  conceptional 
forms,  a  chancre  is  the  starting-point  of  syphilis. 

Filtering,  heating  for  an  hour  to  51°  C,  or  desiccation,  renders  the  virus 
non-inoculable. 

Methods  of  Contagion. — Syphilis  differs  from  the  other  exanthemata  in 
the  slov^-ness  of  its  course,  in  the  comparative  mildness  of  its  constitutional 
svmptom.s,  and  in  requiring  actual  contact  for  its  transmission.  The  method 
of  infection  is  by  inoculation  or  heredity. 

The  contagion  may  be  either  immediate  or  mediate. 

Immediate  contagion — that  is,  contagion  direct  from  one  individual  to  an- 
other— ^usually  takes  place  during  sexual  approach,  though  it  may  occur  from 
unnatural  practices,  from  kissing,  from  wounds  inflicted  by  the  teeth  of  syphi- 
litics, or,  in  the  case  of  medical  men,  from  operating  on  syphilitic  patients, 
when  the  hands  of  the  operator  are  wounded  or  abraded. 

Inoculation  is  more  readily  accomplished  through  a  superficial  abrasion  than 
through  a  deep  woimd. 


SYPHILIS  689 

Mediate  Contagion. — In  this  form  of  contagion  the  disease  is  conveyed 
not  by  direct  surface  contact,  but  by  means  of  spoons,  glasses,  pipes,  clothing, 
etc.,  upon  which  the  specific  virus  is  deposited  by  a  person  suffering  from  some 
of  the  lesions  of  syphilis,  and  from  which  it  is  inoculated  in  some  surface 
break  of  a  person  not  immune  to  the  disease.  The  list  of  articles  which  have 
thus  conveyed  s>^hilis  is  comprehensive.  Among  the  frequent  carriers  of 
contagion  are  pipes,  cigars,  razors,  pencils  and  penholders,  surgical  and  dental 
instruments,  towels,  handkerchiefs,  articles  of  clothing,  and  human  vaccina- 
tion lymph.  Many  unusual  methods  of  contagion  have  been  observ^ed.  Melot 
reports  a  nasal  chancre  developing  in  a  pedestrian  who  was  accidentally  hit 
by  the  whip-lash  of  a  passing  teamster.  The  latter,  who  was  syphilitic,  had 
formed  the  habit  of  biting  his  lash. 

Types  or  Syphilis. — Syphilis  may  begin  and  end  with  chancre  and  in- 
guinal adenitis,  no  other  symptoms  developing.  After  such  a  sore  and  the 
entire  absence  of  secondaries  unmistakable  tertiary  lesions  may  appear  years 
later.  It  seems  reasonable  to  conclude  that  infection  may  exceptionally  be 
so  mild  that  by  systemic  resistance  it  may  remain  permanently  latent  or  be 
radically  cured  in  its  primary  stage. 

The  disease  may  have  for  its  manifestations  a  chancre,  general  adenitis, 
and  one  light  outbreak  of  macular  or  papular  eruption  involving  the  skin  and 
the  mucous  surfaces  of  the  mouth  and  throat,  thereafter  showing  no  signs. 

]More  commonly  following  the  chancre  there  is  a  single  exanthematous 
outbreak,  disappearing  promptly  under  treatment,  but  recurring  occasionally, 
particularly  in  the  mouth  and  throat.  These  recurrences  yield  promptly  to 
vigorous  antisyphilitic  treatment,  and  are  not  followed  by  tertiaries.  The  types 
of  disease  thus  described  are  termed  benign,  but  any  of  them  may  be  followed 
by  tertiary  manifestations  of  the  crippling  and  incurable  form. 

Exceptionally  the  disease  is  distinctly  atypical  in  its  development,  deep 
ulcerating  and  infiltrating  lesions  appearing  in  the  early  secondary'  period. 

This  form  of  the  disease  is  characterized  by  its  acute  course.  Even  the 
chancre  exhibits  a  destructive  tendency,  resembling  in  its  development  phage- 
daenic  chancroid.  Syphilitic  fever,  concomitant  rheumatism,  and  anaemia  are 
well  marked.  The  first  eruption  quickly  becomes  pustular,  and  ulcers  form 
which  are  deep  enough  to  leave  pigmented  scars  on  the  skin,  and  in  the  mouth 
and  nose  to  involve  the  superficial  bones  and  cartilages,  causing  necrosis  and 
deformity.  Deep  ulcers  and  ulcerating  gummata  appearing  in  the  secondary 
period  are  especially  characteristic  of  this  form  of  s\^hilis.  Recurrences  fol- 
lowing hard  upon  one  another  are  also  typical  of  malignant  s}^hihs,  while 
early  involvement  of  the  bones,  the  nervous  system,  and  the  viscera  is  not 
uncommon.     In  the  latter  case  syphilitic  marasmus  and  death  often  result. 

The  malignant  form  of  the  disease  seems  to  depend  not  only  upon  the 
Xy^e  of  infection,  but  also  upon  lessened  tissue  resistance.  Thus.  s\TDhilis  is 
prone  to  exhibit  its  malignant  form  in  the  weak,  the  anaemic,  chronic  drunkards, 
the  scrofulous,  the  tuberculous,  the  malarial,  and  in  pregnant  or  nursing  women. 

There  is  both  clinical  and  laboratory  e\idence  to  show  that  there  are  spiro- 
chaetal  strains,  exhibiting  predilection  for  certain  systems;  thus  there  are 
syphilitics  whose  late  gross  lesions  are  confined  to  the  bones,  others  who  exhibit 

44 


690  GENITO-URINARY  SURGERY 

only  involvement  of  the  central  nervous  system,  and  others  in  whom  eye  lesions 
are  dominant. 

Periods  of  Syphilis. — In  accordance  with  its  clinical  course  the  phe- 
nomena of  acquired  syphilis  are  classed  under  certain  periods. 

1.  The  Period  of  Primary  Incubation. — The  time  intervening  between  ex- 
posure to  contagion  and  the  appearance  of  the  chancre.  This  is,  on  an  average, 
three  to  four  weeks;  its  extremes  are  twelve  days  and  three  months. 

2.  The  Period  of  Primary  Symptoms. — The  chancre  develops  and  the  ana- 
tomically related  lymph-nodes  become  enlarged.  This  symptom-complex  re- 
quires from  three  to  ten  days  for  its  characteristic  development. 

3.  The  Period  of  Secondary  Incubation. — The  time  elapsing  between  the 
appearance  of  the  chancre  and  the  development  of  secondary  symptoms.  This 
is,  on  an  average,  six  to  seven  weeks,  and  includes  the  period  of  primary 
symptoms. 

4.  The  Period  of  Secondary  Symptoms. — Anaemia  and  neuralgic  pains,  slight 
fever,  periosteal,  visceral,  and  meningeal  congestions,  eye  lesions,  and  the 
syphilides  of  the  skin  and  mucous  membranes  develop  during  this  period.  This 
is,  on  an  average,  from  twelve  to  eighteen  months. 

5.  Intermediate  Period. — During  this  time  the  patient  may  be  entirely  free 
from  any  signs  of  syphilis,  or  he  may  suffer  from  slighter,  more  irregular,  less 
symmetrical,  and  less  generalized  symptoms  than  those  of  the  secondary  stage. 
Children  begotten  by  a  patient  in  the  first  half  of  this  stage  of  the  disease 
often  show  the  signs  of  hereditary  syphilis.  This  period  lasts  from  two  to  four 
years.     It  may  terminate  in  complete  recovery  or  may  be  followed  by: 

6.  The  Period  of  Tertiary  Symptoms. — This  is  characterized  either  by  the 
formation  of  gummata  or  by  diffuse  infiltration  of'  various  organs.  Chronic 
periostitis  and  ostitis,  skin  diseases  of  the  tuberculo-ulcerous  type,  diffuse  or 
circumscribed  visceral  infiltration,  disease  of  the  nervous  system,  are  encoun- 
tered during  this  stage.  In  the  majority  of  properly  treated  cases  the  lesions 
of  this  period  never  appear;  though  they  may  develop  at  any  time  subsequent 
to  the  chancre,  they  commonly  are  seen  in  the  third  and  fourth  years  following 
the  primary  lesion. 

This  division  of  syphilis  into  periods  is  roughly  indicative  of  the  course  of 
the  untreated  or  inadequately  treated  disease;  one  period  runs  insensibly  into 
another.  Lesions  of  primary,  secondary,  and  tertiary  s)^hilis  may  all  be 
present  at  the  same  time. 


CHAPTER  XXXIV 
SYPHILIS-(Contiiiued) 

THE   PERIOD    OF   PRIMARY   INCUBATION 

Although  the  virus  of  syphilis  does  not  remain  localized  during  the  entire 
period  elapsing  between  inoculation  and  the  appearance  of  the  chancre,  it 
remains  at  or  near  the  seat  of  inoculation  a  certain  length  of  time,  arid  hence 
for  a  brief  period  may  be  reached  and  destroyed  by  mechanical  cleansing 
and  applications  toxic  to  the  infection. 

It  is  possible  that  syphilis  may  be  acquired  from  contact  with  the  virus 
through  unbroken  surfaces,  especially  where  the  epidermis  is  extremely  thin; 
but  the  presence  of  fissures  or  of  abrasions  greatly  facilitates  the  contraction  of 
the  disease. 

As  a  rule,  it  is  safe  to  assume  that  any  sore  which  appears  more  than  ten 
days  after  the  last  exposure  to  contagion  is  a  chancre.  During  the  period 
of  primary  incubation  there  are  neither  general  nor  local  symptoms;  nor  can  a 
positive  Wassermann  reaction  be  obtained. 

THE    PERIOD    OF    PRIMARY    LESION 

After  the  period  of  primary  incubation  the  primary  lesion  of  syphilis,  a 
chancre,  develops.  This  begins  as  a  spot  of  erythema,  which  in  a  few  hours 
becomes  a  superficial  papule;  it  gradually  extends  in  circumference  and  depth, 
loses  its  epithelial  or  epidermic  covering,  and  in  the  course  of  a  few  days  is 
surrounded  by  an  area  of  induration.  This  represents  the  development  of  a 
typical  chancre.  Frequently,  however,  the  chancre  when  first  seen  appears  as 
a  fissure  or  an  abrasion,  or,  if  located  on  the  mucous  membrane,  as  a  super- 
ficial  ulceration  covered  by  a  grayish  or  yellowish   false  membrane. 

There  may  be  no  break  in  the  continuity  of  the  epidermis  overlying  a 
chancre,  but  merely  a  gradual  thinning  of  this  layer  of  the  skin  from  the 
margins  towards  the  centre. 

The  well-developed  typical  ulcer  appears  as  a  cup-shaped  depression,  with 
sloping  margins  and  smooth  surface,  covered  centrally  by  a  tough  gray  false 
membrane;  beneath  this  there  is  a  granulating  surface,  which  bleeds  readily 
on   mechanical  interference. 

The  chancre  is  usually  single.  When  the  virus  has  been  inoculated  at  the 
same  time  in  several  places  a  number  of  sores  may  appear,  but  they  all  develop 
at  the  same  time,  and  are  never  due  to  inoculation  of  surrounding  or  opposing 
surfaces  with  the  discharge  of  a  first  sore.  Multiple  chancres  occur  in  eighteen 
per  cent.   (Fournier)  of  cases. 

Induration. — In  from  five  to  ten  days  the  most  characteristic  feature  of 
chancre,  the  induration,  becomes  perceptible,  reaching  its  maximum  in  about 
two  weeks  from  the  appearance  of  the  sore.    It  is  distinct  in  the  great  majority 

691 


592  GENITO-URINARY  SURGERY 

of  cases,  but  may  appear  in  different  forms.  It  is  due  to  the  thickening  of  the 
blood-vessel  walls,  in  conjunction  with  the  cellular  infiltration. 

The  blood-vessels  of  the  skin  form  two  horizontal  networks — one  beneath 
the  papillae,  the  other  in  the  deepest  portion  of  the  derm.  When  only  the 
superficial  network  of  vessels  is  sclerosed  there  is  simply  a  surface  thickening 
(laminated  or  parchment  induration) ;  when  both  networks,  together  with  the 
intermediate  branches,  are  affected,  there  is  a  distinct  nodule,  varying  in  thick- 
ness according  to  the  extent  of  skin  surface  involved  (nodular  induration). 
The  vascular  sclerosis  is  continued  far  beyond  the  area  of  induration,  but  usually 
to  such  a  slight  degree  that  the  line  of  demarcation  between  the  borders  of  the 
chancre  and  the  surrounding  tissue  is  distinctly  marked. 

The  induration  of  the  chancre  is  best  detected  by  gently  pinching  together 
the  soft  parts  wide  of  the  lesion  till  the  hardened  edges  are  felt  by  the  thumb 
and  finger  placed  on  opposite  sides  of  the  sore;  the  whole  plaque  is  then 
lifted  upward  from  the  subcutaneous  tissues,  when,  by  further  gentle  pressure 
and  palpation,  the  depth  and  extent  of  the  induration  can  be  readily  deter- 
mined. 

It  varies,  in  some  degree,  in  accordance  with  the  seat  of  the  primary  lesion. 
When  occurring  upon  the  glans  penis,  upon  the  inner  layer  of  the  prepuce,  or 
in  the  fossa  glandis,  the  chancre  is  usually  very  distinctly  indurated.  Upon 
the  skin  of  the  penis  and  the  general  integument  induration  is  not  so  marked. 
In  women  the  induration  of  the  primary  lesion  is  far  less  distinct  than  is  the 
case  with  men;  when  the  chancre  is  situated  upon  the  labia  majora  the  char- 
acteristic hardening  is  more  pronounced  than  when  it  involves  the  labia  minora 
or  the  fourchette. 

The  chancre  cominonly  heals  in  four  to  six  weeks,  the  induration  lasting  not 
much  longer  than  this;  if  it  has  been  distinctly  nodular  in  character,  it  may 
persist  for  months  and  even  years,  or,  after  having  entirely  disappeared,  may 
again  become  marked,  constituting  a  form  of  the  so-called  pseudo-chancre. 

Location    of    the    Chancre 

Genital  chancres  are  those  placed  on  or  about  the  genitalia.  The  great 
majority  of  chancres,  especially  in  men,  are  genital  or  perigenital. 

Chancres  elsewhere  placed  are  termed  extragenital.  The  disease  when 
acquired  in  ways  other  than  by  normal  or  perverted  sexual  congress  is  termed 
syphilis  insontium.  The  extragenital  chancre  may  be  found  on  any  surface 
exposed  to  contact  with  syphilitic  virus.  The  usual  seats  of  such  chancres  are 
the  lips,  the  mucous  surfaces  of  the  mouth  and  pharynx,  the  region  of  the 
anus,  and  the  region  of  the  nipple.  In  the  mouth  the  chancre  is  commonly 
found  on  the  tongue,  exceptionally  on  the  tonsils  or  the  half-arches.  Among 
surgeons,  accoucheurs  and  nurses  extragenital  chancre  is  usually  found  on  the 
fingers  or  hand.  With  very  few  exceptions,  extragenital  chancres  are  acquired 
in  innocent  ways;  even  the  anal  chancres  often  noted  in  women  are  commonly 
due  to  infection  by  discharges  flowing  backward  from  the  vagina.  Extragenital 
chancres  rarely  present  the  typical  features  of  the  sore  as  observed  about  the 
genitalia.  At  times  the  lesions  are  so  slight  as  to  excite  scarcely  any  attention; 
more  commonly  inflammatory  symptoms  become  so  pronounced  that  character- 


SYPHILIS 


693 


Fig.  368. — Chancre  of  the  reflected  layer. 


Fig.  369. — Chancre  of  the  meatus. 


694 


GENITO-URINARY  SURGERY 


istic  induration,  if  present,  is  entirely  masked,  and,  except  in  the  clinical  history 
of  the  case,  there  is  nothing  to  suggest  that  the  sore  is  syphilitic  in  nature. 
Chancres  of  the  face  and  lips  are  often  much  larger  than  the  average  genital 
chancre,  and  sometimes  form  huge  ulcers. 

The  Genital  Chancre. — The  common  position  of  the  genital  chancre  in 
men  is  on  the  inner  layer  of  the  prepuce  in  or  just  behind  the  coronary  sulcus 
(Figs.  368  and  369),  on  the  surface  of  the  glans  penis,  particularly  in  the 
region  of  the  fraenum,  and  about  the  margin  of  the  preputial  opening.  Three- 
fourths  of  all  chancres  are  in  these  localities.     The  primary  sore  is  found  at 

times  at  the  meatus  urinarius,  on  the  skin 
of  the  penis  (Plate  XII),  on  the  groin  or  the 
scrotum,  and  in  the  urethra.  The  character- 
istic induration  is  most  marked  in  those 
chancres  found  at  the  seats  of  preference — 
i.e.,  on  the  inner  layer  of  the  prepuce  just 
behind  the  sulcus.  Upon  the  surface  of  the 
glans,  in  the  region  of  the  frsenum,  and  about 
the  urinary  meatus  the  sore  frequently  as- 
sumes a  distinct  inflammatory  type  (Fig. 
370). 

On  the  free  edge  of  the  prepuce  the  in- 
duration may  be  absent  or  may  form  a  ring 
of  great  hardness. 

In-  women  chancres  are  commonly  placed 
on  the  labia  majora  or  labia  minora.  They 
are  not  infrequently  found  in  the  regions  of 
the  fourchette  and  the  clitoris,  and  have  oc- 
casionally been  observed  about  the  os  uteri. 
They  are  rare  upon  the  surface  of  the  vagina, 
although  this  canal  is  probably  more  exposed 
to  contagion  than  any  other  surface.  This 
immunity  is  due  to  the  structure  of  the  vaginal 
mucous  membrane,  which,  being  guarded  with 
thick  layers  of  flat  epithelial  cells,  and  having 
no  glandular  orifices,  forms  an  efficient  bar- 
rier against  microbic  infection.  The  inguinal 
lymph-nodes  are  primarily  involved  only 
when  the  lesion  is  placed  in  the  anterior  third  of  the  canal. 

The  typical  sharply  circumscribed  cartilaginous  hardening  is  rarely  observed 
in  women;  it  is  replaced  by  a  more  diffuse  and  less  sharply  marked  infiltration, 
often  little  greater  than  would  attend  a  non-specific  lesion  of  the  same  size. 

Varieties   of  the   Genital    Chancre. — Although  the  primary  lesion   may 
appear  in  a  great  variety  of  forms,   the  majority  of   cases  present   certain 
characteristic  features,  enabling  them  to  be  considered  under  a  few  headings. 
In  the  order  of  their  relative  frequency  chancres  may  be  classed  as: 

1.  Chancrous  erosions. 

2.  Chancrous  ulcerations. 

3.  Indurated  papules. 


Fig.  370. — Chancre  of  the  coronary  sulcus. 


PLATE  XII. 


Chancre  on  shaft  of  penis. 


SYPHILIS  695 

Exceptionally  there  are  observed  certain  erratic  forms  of  chancre  which 
would  not  strictly  fall  under  any  of  these  headings.  Among  these  are  en- 
countered : 

1.  The  multiple  herpetiform  chancre,  closely  resembling  herpes,  -but  not 
presenting  the  multiple  circinate  margin  of  the  latter,  not  giving  the  characteristic 
exudation  of  herpes  on  pressure,  and  having  a  different  clinical  histor\^ 

2.  The  "silvery  spot,"  a  lesion  such  as  would  be  produced  by  the  application 
of  a  finely  pointed  silver  nitrate  stick,  generally  situated  on  the  surface  of  the 
glans  penis,  and  often  giving  place  finally  to  the  chancrous  erosion. 

3.  The  mixed  chancre,  a  lesion  which  results  from  the  action  of  both  the 
chancroidal  and  the  syphilitic  virus.  The  chancroid  runs  its  typical  course  and 
may  be  healed  before  the  syphilitic  induration  is  noted.  More  frequently  there 
is  a  persistent  chancroidal  ulceration,  around  which  the  hardening  of  the  true 
chancre  appears  at  its  regular  time. 

1.  The  Chancrous  Erosion. — About  two-thirds  of  all  genital  chancres  appear 
in  the  form  of  chancrous  erosions.  The  lesion  at  first  looks  like  a  small 
abrasion,  such  as  might  result  from  a  very  slight  scratch  with  the  finger-nail. 
As  the  chancre  develops  it  becomes  oval  or  round  in  shape,  is  surrounded  by 
a  dusky-red  areola,  presents  a  polished  raw  surface,  the  central  portion  of 
which  is  covered  by  a  gray  false  membrane,  and  discharges  a  small  quantity  of 
blood-stained  serum.  The  lesion  is  an  exfoliation  of  the  epiderm,  exposing  but 
not  destroying  the  true  skin.  The  induration  develops  in  about  a  week  from 
the  beginning  of  the  erosion,  and  is  usually  parchment-like,  though  it  may 
be  nodular. 

2.  The  Chancrous  Ulceration. — This  form  of  chancre  exhibits  a  deeper 
ulceration  than  the  chancrous  erosion.  The  latter  causes  epithelial  desquama- 
tion; the  former  involves  the  true  skin,  or,  in  its  more  exaggerated  form,  the 
subcutaneous  tissues. 

The  chancrous  ulceration  may  be  superficial  or  deep. 

The  superficial  form  of  chancrous  ulceration,  called  by  Fournier  the  exul- 
cerative  chancre,  attacks  the  true  skin,  but  does  not  entirely  destroy  it.  An 
ulcer  is  formed  of  moderate  depth,  with  sloping  edges  and  a  scanty  sero-san- 
guineous  discharge. 

The  granulating  surface  is  frequently  covered  by  a  gray  adherent  false 
membrane.  The  induration  is  more  marked  than  in  the  chancrous  erosion,  being 
rather  of  the  nodular  than  of  the  parchment  variety. 

The  deep  form  of  chancrous  ulceration,  called  by  Fournier  the  ulcerative 
chancre,  is  comparatively  rare. 

There  is  formed  a  deep  ulcer  with  sloping  edges,  moderate  sero-sanguineous 
discharge,  and  typical  extensive  cartilaginous  induration  into  which  the  ulcer 
seems  to  have  eaten. 

3.  The  Indurated  Papule. — This  primary  lesion  of  syphilis  differs  from  the 
chancrous  erosion  in  the  fact  that  the  skin  is  not  broken.  A  hard,  raised,  dusky- 
red  tubercle  is  formed,  sharply  defined  from  the  surrounding  tissues.  The 
surface  is  dry,  but  is  frequently  crusted  with  layers  of  exfoliated  epithelium. 
The  papule  may  be  large  and  prominent,  or  so  small  as  to  escape  the  notice  of 
the  patient. 


696  GENITO-URINARY  SURGERY 

Complications   of   Chancre 

The  types  of  genital  chancre  just  described  may  be  so  modified  that  they 
present  an  appearance  entirely  different  from  that  commonly  supposed  to  be 
characteristic  of  the  primary  lesion  of  syphiHs. 

The  modification  may  be  brought  about  by:  1,  simple  inflammation;  2, 
chancroidal  inflammation;  3,  papillary  growth;  4,  conversion  into  a  mucous 
patch;  5,  phagedena  and  gangrene. 

Simple  inflammation  may  attack  a  chancre  as  a  result  of  inoculation  with 
the  ordinary  microorganisms  of  suppuration.  This  will  be  more  likely  to  take 
place  if  the  chancre  is  exposed  to  irritating  applications,  to  friction,  or  to  any 
mechanical  injury  which  will  render  the  soil  favorable  to  the  multiplication  of 
pyogenic  microbes.  The  chancre  will  be  modified  by  the  local  signs  of  acute 
inflammation — namely,  heat,  pain,  redness,  swelling,  and  free  discharge.  As  a 
further  complication,  suppurating  buboes  may  form  in  the  groins. 

Chancroidal  Inflammation. — The  virus  of  chancroid  and  that  of  syphilis 
may  be  inoculated  at  the  same  time.  In  this  case  the  chancroid  will  appear 
first,  and  may  even  have  run  its  course  and  be  completely  cicatrized  before 
the  characteristic  induration  of  the  chancre  is  noted.  More  commonly  the 
chancroid  persists,  the  spreading,  inflamed,  sloughing-punched-out,  freely  dis- 
charging ulcer  becoming  gradually  enveloped  in  a  hardened  infiltrate  as  the 
period  for  the  full  local  development  of  the  syphilitic  lesion  is  reached.  In 
place  of  being  acquired  at  the  same  time,  the  chancroidal  virus  may  be  in- 
oculated on  a  well-developed  chancre;  the  result  of  this  will  be  the  formation 
of  a  chancroid,  the  induration  being  the  only  remaining  local  symptom  to  sug- 
gest chancre.  If  the  chancroid  spread  rapidly  it  may  cause  sloughing  of  the 
indurated  area,  in  that  case  leaving  no  local  sign  which  would  suggest  syphilis; 
or  the  syphilitic  virus  may  be  inoculated  on  the  chancroid,  the  latter  then 
running  its  course  unaltered  except  for  the  formation  of  an  induration. 

A  sore  resulting  from  the  inoculation  of  both  syphilis  and  chancroid  at  the 
same  spot,  a  mixed  chancre,  is  liable  to  any  of  the  complications  which  follow 
the  inoculation  of  either  of  the  poisons  separately. 

Papillary  Outgrowth  and  Conversion  of  the  Chancre  into  a  Mucous  Patch 
or  Condyloma. — Associated  with  the  chancre  there  may  be  an  abundant  out- 
growth of  warts,  such  as  are  common  in  balanoposthitis  or  other  inflammatory 
conditions  of  the  glans  and  the  prepuce.  These  warts  seem  to  be  due  simply 
to  irritation,  and  are  not  specific  in  their  nature.  The  chancre  itself  at  times 
loses  its  induration  as  secondary  symptoms  develop,  becomes  covered  with  gray 
false  membrane,  and  presents  all  the  characteristics  of  a  mucous  patch;  or  the 
papillary  layer  of  the  skin  may  proliferate,  forming  a  condyloma,  a  broad,  flat 
elevation,  the  surface  of  which  is  covered  with  a  gray,  adherent  pellicle. 

Phagedccna  and  Gangrene. — Phagedsena  may  be  regarded  as  the  result  of 
inflammation  more  rapid  and  intense  than  that  which  characterizes  the  inflamed 
chancre.  The  engorgement  becomes  so  great  that  there  is  loss  of  vitality,  and 
sloughs  are  formed,  or  gangrene  may  attack  the  tissues.  More  rarely  it  pro- 
gresses slowly,  the  ulcerating  process  being  then  termed  serpiginous. 

Phagedsena  is  more  liable  to  occur  in  persons  of  depressed  constitution,  yet 


SYPHILIS  697 

it  is  noted  at  times  in  the  robust.  There  is  undoubtedly  a  systemic  predis- 
position, which  is  in  many  cases  successfully  combated  by  specific  treatment; 
the  exciting  cause  is,  however,  purely  local;  this  is  shown  by  the  fact  that  in 
the  same  person  one  sore  may  become  phagedaenic  while  another  pursues  an 
uncomplicated  course. 

Phagedaena  may  attack  the  chancre  at  any  stage  of  its  development,  or  may 
complicate  any  of  the  secondary  or  tertiary  ulcerations  of  the  disease.  If  rapid, 
it  destroys  the  induration  more  quickly  than  it  can  form,  and  thus  removes 
the  most  characteristic  feature  of  the  chancre. 

Diagnosis    of   Chancre 

In  its  early  development  chancre  cannot  be  recognized  as  such  by  inspection 
or  palpation.  Since  early  diagnosis  is  of  major  importance,  all  inflammatory 
genital  lesions  which  cannot  be  accounted  for  on  the  basis  of  recent  (three  days') 
exposure  or  slight  trauma,  and  which  cannot  with  assurance  be  given  a  different 
diagnosis,  should  be  regarded  as  possibly  syphilitic  on  their  first  appearance, 
as  probably  syphilitic  if  two  or  three  days  of  cleanliness  and  protection  do  not 
accomplish  their  marked  betterment  or  cure,  as  surely  syphilitic  if  in  from  five 
to  seven  days  induration  and  typical  inguinal  adenitis  develop. 

The  primary  lesion  of  syphilis  may  present  only  the  features  of  a  simple 
ulcer.  A  positive  opinion  cannot  be  given  from  the  examination  of  the  sore 
alone. 

The  absolute  diagnosis  of  chancre  is  made  by  finding  the  treponemata  (see 
Chapter  XLIII). 

In  the  absence  of  microscopic  examination,  an  opinion  as  to  the  nature  of 
a  genital  sore  will  be  formed  after  due  consideration  of  the  following  points: 

1.  Confrontation,  or  examination  of  the  person  from  whom  the  lesion  was 
presumably  acquired.  Even  though  he  or  she  is  found  to  be  suffering  from 
symptoms  of  primary  or  secondary  syphilis,  the  lesions  are  not  necessarily 
specific;  they  may  be  of  mechanical,  herpetic,  or  chancroidal  origin.  This 
method  of  diagnosis  is  rarely  practicable. 

2.  The  History  of  Incubation.- — A  lesion  developing  in  less  than  five  days 
from  exposure  is  certainly  not  specific.  One  developing  in  from  ten  days  to  five 
weeks  is  probably  specific,  unless  some  other  cause,  such  as  mechanical  or 
chemical  irritation,  or  fresh  exposure,  can  be  assigned  for  it,  or  unless  it  be 
frankly  herpetic  or  transitory. 

3.  The  Development  of  the  Lesion. — When  this  begins  as  a  macule,  or  slight 
painless  excoriation,  or  scratch,  which  persists  in  spite  of  careful  local  treatment, 
which  slowly  spreads  without  marked  inflammatory  symptoms,  which  becomes 
distinctly  hard  peripherally  and  at  the  base  as  though  there  were  a  dense  cellular 
infiltrate,  and  which  gives  a  thin,  scanty  discharge,  showing  a  tendency  to  crust 
or  to  form  a  pseudo-membranous  deposit  covering  the  excoriated  surface,  the 
diagnosis  of  chancre  can  be  made  with  considerable  confidence. 

4.  Induration. — When  the  lesion,  be  it  papule,  erosion,  or  ulcer,  develops  the 
laminated,  parchment,  or  nodular  induration,  a  sharply  circumscribed  hardening, 
spreading  wide  of  the  central  lesion  and  absolutely  unlike  the  general  thick- 
ening about  an  area  of  simple  inflammation,  it  is  almost  certainly  a  chancre. 


698  GENITO-URINARY  SURGERY 

5.  Lymphatic  Involvement. — If  the  dorsal  lymph-vessels  of  the  penis  become 
thickened  and  hard,  and  lymph-nodes  of  the  groin  steadily  increase  in  size  and 
hardness,  without  accompanying  pain  or  other  symptom  of  acute  inflammation, 
forming  a  chain  of  little  tumors,  including  several  or  all  of  the  inguinal  nodes 
of  both  sides,  the  evidence  as  to  the  specific  nature  of  a  genital  lesion  is  still 
further  strengthened. 

The  chief  considerations  on  which  a  clinical  diagnosis  is  founded  are,  the 
period  of  incubation,  the  presence  or  absence  of  induration,  and  the  condition 
of  the  anatomically  related  lymph-nodes,  and,  most  important  of  all,  the  per- 
sistence of  the  lesion. 

Difficulties  of  diagnosis  are  greatest  during  the  first  week  or  ten  days,  and 
steadily  diminish  with  the  age  of  the  lesion,  which,  if  syphilitic,  is  almost 
certain  to  show  the  characteristics  of  the  chancre.  Confrontation  is  seldom 
practicable.  The  history  of  incubation  is  often  vague  and  uncertain,  and  the 
development  of  the  lesion  is  rarely  studied  attentively  by  the  patient. 

Induration  is  present  in  the  great  majority  of  chancres,  and  when  typically 
developed  is  almost  enough  to  justify  a  positive  diagnosis.  Induration,  how- 
ever, may  fail  as  a  diagnostic  sign,  since — 1,  it  may  be  absent  or  but  slightly 
developed;  2,  it  may  be  masked;  3,  it  may  be  present  in  non-specific  ulcers; 
4,   it  may  be  present   in  relapsing  chancres. 

The  initial  lesion  sometimes  appears  as  an  infecting  balanoposthitis,  differ- 
ing from  ordinary  balanoposthitis  only  in  thickening  and  hardening  of  the  pre- 
puce, but  slightly  greater  than  that  observed  as  a  result  of  simiple  untreated 
inflammation;  or  syphilis  may  be  inaugurated  by  the  multiple  herpetiform 
chancre,  which  may  become  indurated  to  only  a  moderate  degree. 

Induration  may  be  masked  by  cellular  infiltration  dependent  upon  acute 
inflammation  attacking  a  chancre,  or  may  be  entirely  destroyed  by  a  rapid 
phagedsenic  process. 

Certain  non-specific  sores  may  present  induration  so  like  that  of  the  chancre 
that  differential  diagnosis  founded  on  this  sign  alone  cannot  be  made.  A  simple 
sore  which  has  been  treated  by  caustics  will  frequently  take  on  induration.  A 
forming  furuncle,  the  inflamed  orifice  of  a  suppurating  vulvo-vaginal  gland,  a 
tubercular  ulcer,  an  isolated  lesion  of  scabies,  may  all  present  a  circumferential 
induration  which  will  make  immediate  diagnosis  impossible. 

The  so-called  relapsing  chancre,  generally  a  tertiary  lesion,  may,  with  the 
exception  of  the  inguinal  adenopathy,  exactly  simulate  the  primary  sore  of 
syphilis. 

The  involvement  of  the  anatomically  connected  lymph-nodes  is  absent  as  a 
rare  exception;  when  typical  it  is  highly  characteristic.  It  must  be  borne  in 
mind,  however,  that: 

1.  Many  non-syphilitic  patients  exhibit  hard,  movable  lymphatic  tumors 
in  both  groins. 

2.  Simple  sores  sometimes  cause  enlargement  of  several  nodes  with  very  slight 
inflammatory  phenomena.  Occasionally,  from  mixed  infection,  syphilitic  buboes 
exhibit  marked  inflammatory  reaction. 

3.  Chancre  may  be  followed  by  secondary  syphilis  without  involvement  of 
the  anatomically  related  lymph-nodes. 


PLATE  XIII. 


Chancre  of  the  corona.    (Fox.) 


SYPHILIS 


699 


The  Differential  Diagnosis  of  Genital  Chancre 

Since  ulcerative  lesions  of  the  genitalia  may  be  due  to  a  variety  of  causes, 
and  since,  even  though  different  in  their  nature,  they  may  present  some 
features  in  common,  the  question  of  differential  diagnosis  becomes  one  of  great 
importance. 

To  distinguish  between  a  "  mixed  chancre  "  and  a  chancroid  or  simple  veneral 
ulcer  is  often  impossible.  Even  should  a  chancroid  be  absolutely  typical  in 
all  its  clinical  features,  it  is  not  safe  to  make  a  positive  statement  that  syphilis 
will  not  develop.  If,  in  spite  of  the  favorable  course  of  a  simple  ulcer,  after 
two  or  three  weeks  characteristic  induration  develops,  and  in  another  seven 
days  the  inguinal  nodes  on  both  sides  painlessly  enlarge  one  after  another, 
the  probability  of  syphilis  and  chancroid  having  been  inoculated  at  the  same 
point  is  great.  Per  contra,  if  a  non-inflammatory  indurated  sore  appears  at  an 
interval  of  more  than  ten  days  after  exposure,  and  in  consequence  of  further 
exposure  rapidly  assumes  an  inflammatory  type,  sloughs,  and  extends  beyond 
the  area  of  induration,  destroying  the  latter,  and  presenting  on  examination  only 
the  features  of  the  simple  venereal  sore,  the  probability  is  that  the  lesion  is  a 
mixed  chancre,  the  chancroidal  virus  having  been  inoculated  upon  the  primary 
lesion.  This  probability  is  made  still  stronger  if  painless  multiple  enlarged 
lymph-nodes  are  found  in  the  groins.  Even  should  a  suppurating  bubo  form, 
this  should  not  influence  the  diagnosis  in  regard  to  syphilis,  since  each  disease 
will  run  its  course  independent  of  the  other. 

The  differential  diagnosis  between  chancre,  chancroid,  aside  from  the  micro- 
scopic identification  of  the  treponema  or  the  Ducrey  bacillus,  and  herpes  will 
depend  upon  a  consideration  of  the  characteristics  of  each  as  given  in  the  follow- 
ing table 

Chancroid.  Herpes. 

Due  to   inoculation  with         Due  to — 

the      discharge      of      a        (1)  Mechanical  irritation, 
chancroidal  sore.    Pos-  as      in      sexual      inter- 

sibly     caused     by     pus  course, 

from  other  sources.  (2)     Chemical    irritation, 

such  as  is  produced  by 
acrid  discharges  or  by 
uncIeanHness. 
(3)  To  neuroses;  often 
following  fever,  and 
particularly  occurring 
in  syphilitics. 
None. 


Chancre. 
Origin. — Due  to  inocula- 
tion with  the  blood  or 
lesion-discharges    of    a 
syphilitic. 


Incubation. — From  ten 
days  to  twelve  weeks. 
Average  about  three 
weeks. 

Situation. — Generally  on 
the  genitalia.  Often 
on  lips,  tongue,  nip- 
ples, and  hands. 


N  u  tn  her.  —  Single  ;  at 
times  simultaneously 
multiple. 

Beginning.  —  Begins  as  an 
erosion,  papule,  tuber- 
cle, or  ulcer.  May  re- 
main without  ulcera- 
tion through  its  entire 
course. 


No  definite  period.  It 
may  not  be  noticed  for 
two  or  three  days. 

Generally  on  the  glans 
penis  and  the  prepuce. 
Rarely  on  other  geni- 
tal surfaces.  Hardly 
ever  on  other  parts  "of 
the  body. 

Frequently  multiple,  of- 
ten on  opposing  sur- 
faces by  auto-inocula- 
tion. 

Begins  as  a  pustule  or  an 
ulcer..  Always  ulcer- 
ates. 


Generally    on    the    glans 
penis     and     the     inner 
layer    of    the    prepuce, 
the  lips,   or  tongue. 
Plate  XII. 

Multiple.  Ultimately 

may   be   confluent. 


Begins  as  a  group  of 
vesicles,  which  may 
coalesce  or  may  ulcer- 
ate singly. 


700 


GENITO-URINARY  SURGERY 


ChaJicrc. 
Shape. — Round,    oval,    or 
symmetrically    irregular. 


Depth. — Usuall}^  superfi- 
cial, cup-shaped,  or 
saucer-shaped,  or  may 
be  elevated. 

Surface. — Smooth,  shin- 
ing, dusky  red,  glazed; 
diphtheroid  m  e  m- 

brane,  or  scab  or  epi- 
thelial crusts. 

Secretion.  —  Scanty,  ser- 
ous, hardly  ever  auto- 
inoculable,  except  in 
cases  of  mixed  infec- 
tion, when  a  chan- 
croidal sore  may  be 
produced.  On  squeez- 
ing no  discharge  is  ex- 
pressed. 

Induration.  —  Usually 
present;  firm,  cartil- 
aginous, or  parchment- 
like ;  sharply  circum- 
scribed; movable  upon 
subjacent  parts.  Pro- 
longed pressure  by  the 
examining  fingers  does 
not  produce  any 
change  in  it;  usually 
persistent;  disappears 
under  specific  treat- 
ment. 

Sensibility. — Very  rarely 
painful. 

Course. — Groves  slowly 
and,  as  a  rule,  pain- 
lessly larger,  in  spite 
of  any  but  specific 
treatment,  for  two  to 
four  weeks;  it  then 
slowly  heals.  Re- 
lapses and  phagedsena 
uncommon. 


Histology. — A  new  cell 
growth.  Very  little 
destruction  of  tissue. 
Scrapings  often  show 
more  or  less  epithe- 
lium. 

Bubo. — Constant,  painless, 
multiple,  generally  bi- 
lateral. 


Chancroid. 

Round,  oval,  or  unsym- 
metrically  irregular, 
with  border  described 
by  segments  of  large 
circles. 

Hollow,  excavated,  or 
"  punched  out." 


Rough,  imeven,  "worm- 
eaten,"  warty,  grayish, 
pultaceous   slough. 


Abundant,  purulent, 
readily  auto-inocu- 
lable. 


Exceptionally  p  r  e  s  e  nt. 
Due  to  caustics  or 
other  irritants,  or  to 
simple  inflammation; 
bogg}',  inelastic, 
shades  oflf  into  sur- 
rounding parts,  to 
which  it  is  adherent; 
disappears  soon  after 
cicatrization.  Pro- 

longed pressure  causes 
changes  in  shape,  such 
as  are  noted  in  oedem.a. 

Often  painful. 

Irregular;  rapid  exten- 
sion: acutely  inflam- 
matory, destructive,- 
and  painful;  runs  its 
course  in  three  to  six 
weeks.  Relapses  and 
phagedsena  not  un- 
common. 


An  ulceration,  with  more 
or  less  loss  of  sub- 
stance. Scrapings 
show  granulation-tis- 
sue. 

Appears  onh^  in  one- 
third  of  the  cases; 
painful,  inflammatory, 
single,  or  a  single  one 
on  each  side. 


Herpes. 
Irregular,    circinate    bor- 
ders, representing  seg- 
ments of  small  circles; 
sometimes    separated. 

Superficial. 


Bright  red  superficial 
granulations,  some- 
times covered  by  diph- 
theroid membrane. 

Moderate  secretion, 

auto-inoculable  with 
difficulty.  On  squeez- 
ing a  small  serous 
drop  exudes.  When 
this  is  wiped  away,- 
another  drop  can  be 
pressed  out.  This  can 
be  repeated  several 
times. 

No   induration. 


Often  painful. 

Easily  and  quickly  cured 
(days).  Sometimes 

spreads  by  the  appear- 
ance of  successive 
crops  of  vesicles.     Le- 

■  sions  preserve  the  pol- 
ycyclic  form.  Likely 
to   recur,    especially   in 

■  syphilitics  and  in  un- 
cleanly patients  with 
long   foreskins. 

Originally  an  elevation 
of  the  epidermis  in 
spots  by  an  effusion  of 
serum. 


Rare.  When  it  does  oc- 
cur, painful  inflamma- 
tory, single,  or  a  single 
one  on  each  side. 


SYPHILIS 


701 


Chancre. 

Prognosis. — Good  locally ; 
ulceration  is  at  the  ex- 
pense of  the  infiltrate: 
hence  there  is  little  ul- 
timate scarring;  con- 
stitutional syphilis  fol- 
lows in  the  great  major- 
ity of  cases. 

Treatvicnt. — Rapidly  cur- 
ed by  systemic  treat- 
ment. 


Chancroid. 
More  serious  locally,  for 
there  is  tissue  destruc- 
tion. May  refuse  to 
heal  or  may  become 
phagedenic.  Never 
followed  by  syphilis 
(unless    mixed). 

Local  treatment  is  slow- 
ly curative.  (Usually 
rapid  healing  after 
cauterization). 


Herpes. 
Always  good.  Recur- 
rences are  frequent,  es- 
pecially in  syphilitics. 
(The  herpetic  chancre 
closely  simulates  her- 
pes). 


Local  treatment  is  rapidly 
curative.  Tendency  to 
spontaneous  cure. 


When  phimosis  is  present,  so  that  a  lesion  of  the  glans  or  of  the  under  surface 
of  the  foreskin  cannot  be  exposed,  it  is  difficult  to  determine  whether  such  a 
lesion  is  chancrous  or  is  due  to  inflammatory  processes  of  a  different  nature. 
In  such  cases  a  diagnosis  must  be  made  after  a  consideration  of  the  following 
points  of  difference: 


Subprepntial  Chancre. 

Incubation.  —  Never  less  than  ten  days. 
L^sually   three   weeks;   may   be   more. 

Number. — The  lesion  is  usually  single. 
(This  may  be  learned  from  the  his- 
tory of  the  case  before  phimosis  de- 
veloped,  or   from   palpation.) 


In-fiamination. — Acute     symptoms 
or    but    slightly    marked. 


absent 


Swelling. — Hard,  characteristic  circum- 
scribed induration.  Can  often  be 
isolated  from  surrounding  tissues  and 
raised  and  felt  between  the  thumb 
and  finger. 


Discharge. — Moderate, 
blood-stained.  Not 
oculable. 


thin,     at     times 
readily     auto-in- 


Preputial   Orifice. — Not  markedly  ulcer- 
ated. 

Buboes. — Non-inflammatory,       bilateral, 
inguinal  buboes  always  develop. 


Non-Syphilitic  Subpreputial  Ulceration. 

Incubation.— Rarely  none.  Inflamma- 
tory symptoms  become  pronounced 
in  less  than  ten  days. 

Number. — The  lesions  are  usually  mul- 
tiple. 


Inflammation. — Acute  symptoms  very 
pronounced.  (Heat,  swelling,  pain, 
redness.) 

Swelling. — Dififuse,  oedematous  general 
inflammatory  infiltration.  Cannot  be 
isolated  or  felt  as  a  circumscribed  in- 
duration. 


Discharge. — Often  produces  auto  inocu- 
lation  by   accidental   contact. 


Preputial     Orifice. — Almost     invariablv 
ulcerated. 

Buboes. — Single,    inflammatory,    suppu- 
rating  buboes    often    develop. 


Concealed  Genital  Chancres. — Typical  chancre  may  develop  about  the 
genitalia,  yet  from  the  fact  that  it  is  so  placed  as  to  be  concealed  from  view  it 
may  not  be  detected;  thus  chancres  of  the  cervix  uteri  and  chancres  of  the 
urethra  are  not  usually  recognized  as  such  till  constitutional  symptoms  develop. 

Chancre  of  the  cervix  uteri  is  probably  more  common  than  is  generally 
believed.  It  is  often  not  discovered  because  the  lesion  thus  placed  produces  no 
pain  and  but  very  slight  discharge:  hence  there  are  no  symptoms  which  would 
lead  a  patient  to  present  herself  for  examination. 


702  GENITO-URINARY  SURGERY 

The  chancre  is  nearly  always  situated  at  the  margin  of  the  os,  and  presents 
the  same  variations  in  size  and  surface  as  are  notea  in  primary  sores  of  the 
external  genitalia.  It  may  appear  as  an  erosion,  as  a  deep  ulceration  with  a 
smooth  pseudo-membranous  surface,  or  as  a  papillary  outgrowth.  It  may  be 
no  larger  than  a  split  pea,  or  may  present  a  raw  surface  the  size  of  the  thumb- 
nail. Induration,  though  present,  cannot  be  felt,  owing  to  the  position  of  the 
lesion.  Chancre  of  the  cervix  must  be  distinguished  from  ulcerating  folliculitis, 
from  mechanical  erosions  and  ulcerations,  from  herpes,  and  at  times  from 
malignant  growths. 

Ulcerating  folliculitis  is  commonly  associated  with  a  chronic  catarrhal  con- 
dition, and  produces  small,  often  multiple  lesions,  extending  very  little  beyond 
the  limits  of  the  follicle.  These  lesions  promptly  heal  under  appropriate 
treatment. 

Mechanical  erosions  and  ulcerations  may  closely  simulate  the  specific  lesion, 
but  are  less  sharply  circumscribed  and  do  not  show  the  characteristic  regular 
development  of  the  specific  sore. 

Herpetic  lesions  can  be  distinguished  from  chancre  of  the  cervix  by  the  fact 
that  the  former  are  usually  multiple,  often  coalesce,  presenting  a  circinate  mar- 
gin formed  of  the  segments  of  many  circles,  and  heal  rapidly. 

Cancer  occurs  at  an  age  when  chancre  is  not  common;  its  course  is  often 
painful  and  always  progressive.  It  causes  deep  ulceration  and  steadily  infiltrates 
surrounding  tissues.  If  at  first  glance  a  chancre  resembles  cancer,  the  further 
progress  of  the  case  will  shortly  decide  the  diagnosis. 

Chancre  of  the  Meatus. — When  the  sore  involves  the  meatus  it  looks  more 
like  a  chancroid  than  like  a  chancre  (Fig.  369^.  From  frequently  repeated 
irritation  incident  to  the  flow  of  urine,  the  lesions  become  distinctly  inflamma- 
tory in  type;  they  are  ulcerative  and  destructive,  showing  jagged,  punched-out 
borders,  and  but  moderate  induration,  best  detected  by  taking  the  end  of  the 
glans  between  the  thumb  and  the  forefinger  and  squeezing  it  in  an  antero- 
posterior direction.  Permanent  cicatricial  deformity  is  often  left  after  they 
have  healed.  Chancre  is  perhaps  more  prone  to  develop  at  the  meatus  than  is 
chancroid ;  hence  a  sore  in  this  region  should  be  suspected,  even  though  it  exhibits 
none  of  the  clinical  features  of  the  S3^hilitic  lesion. 

Urethral  chancre  is  often  overlooked,  not  because  of  the  absence  of  char- 
acteristic features,  but  rather  because  the  lesion  in  this  locality  is  so  rare  that 
methodical  search  is  not  made  for  it.  As  would  naturally  be  expected,  the 
chancre  is  generally  at  or  near  the  meatus.  It  is  rarely  placed  farther  back  than. 
the  fossa  navicularis  (see  Syphilitic  Urethritis). 

EXTRAGENITAL    CHANCRE 

Errors  or  difficulties  in  diagnosis  may  arise  from  the  fact  that  a  chancre  is 
extragenital. 

As  a  rule,  chancroid  is  found  only  about  the  genital  organs:  hence  in  other 
regions  the  question  of  distinguishing  between  this  sore  and  chancre  rarely  comes 
up.     The  extragenital  lesion  is  usually  single. 

Its  favorite  seats  have  been  given. 


SYPHILIS  703 

Herpetiform  erosions  of  the  lips,  papules  on  the  tip  of  the  tongue,  scabby 
ulcerations  of  the  skin,  scratches  which  absolutely  refuse  to  heal,  chronic 
inflammations  at  the  tips  of  the  fingers,  resembling  felons,  but  without  the 
accompanying  acute  inflammatory  symptoms — all  such  lesions  should  be  re- 
garded with  suspicion  if  indolent  in  course,  obstinate  to  treatment,  and  accom- 
panied by  slight  discharge  which  has  a  tendency  to  form  crusts  or  a  pseudo- 
membranous deposit  on  the  eroded  surface.  If,  moreover,  such  lesions  are 
placed  upon  an  elastic,  sharply  circumscribed,  indurated  base,  and  are  followed 
by  hard,  painless  enlargement  of  the  nearest  associated  group  of  lymphatic 
glands,  the  diagnosis  receives  strong  corroboration.  It  is  made  absolutely  cer- 
tain by  finding  the  treponemata. 

Chcincres  of  the  Head  and  Face 

Razor-cuts  on  the  chin,  cheek,  or  lips  which,  after  having  healed,  reopen 
and  become  covered  with  crusts,  pseudo-furuncles  or  acneiform  pustules,  and 
cracks  around  the  mouth  or  nose  which  persist,  are  painless,  are  surrounded 
by  an  area  of  inflammatory  cedematous  swelling,  and  give  a  thin,  blood-stained 
discharge  which  exhibits  a  tendency  to  form  crusts,  should  suggest  the  possibility 
of  chancre,  and  should  lead  to  repeated  microscopic  examination  and  palpation, 
of  the  parotid  and  submaxillary  lymph-nodes. 

The  primary  sore  of  syphilis  when  it  occurs  on  the  scalp  or  on  the  bearded 
cheeks  or  chin  closely  resembles  ecthyma.  On  removing  the  surrounding  and 
covering  hair,  a  glazed,  flat,  slightly  elevated  superficial  ulceration  is  detected. 
When  a  patient  presents  himself  with  such  lesion  it  is  impossible  from  the  local 
signs  to  determine  whether  or  not  the  sore  is  specific.  Early  diagnosis  must  be 
made  with  the  microscope.  Painless  enlargement  and  hardening  of  the  nearest 
lymphatic  nodes  is  strongly  suggestive.  The  ecthymatous  lesion  begins  as  a  flat 
pustule,  surrounded  by  an  acute  inflammatory  but  non-indurated  base,  is  gener- 
ally multiple,  and  runs  its  course  in  two  or  three  weeks. 

The  eyelids  and  the  ocular  conjunctiva  may  be  the  seats  of  primary  sores. 
The  lesion  begins  as  a  papule,  which  gradually  becomes  indurated  and  eroded 
or  ulcerated,  presenting  the  characteristic  sloping  edges  and  hard  base  of  chancre. 
This  lesion  has  often  been  mistaken  for  a  stye;  its  development,  persistence^ 
and  the  absence  of  acute  inflammatory  symptoms  should  suggest  a  microscopic 
examination  in  a  few  days.  Lymphatic  enlargement  is  first  noted  in  the  nodes 
in  front  of  the  ear  and  at  the  angle  of  the  jaw. 

At  times  chancre  of  the  head  and  face  attains  enormous  size,  differing 
entirely  in  appearance  from  the  primary  lesion  of  syphilis  as  ordinarily  observed ; 
induration  may  be  absent,  and  occasionally  acute  inflammatory  symptoms  are 
pronounced.  Such  cases  are  often  not  recognized  till  the  appearance  of  the 
secondary  eruption. 

Chancre  of  the  Lip. — Chancre  of  the  lip  in  its  beginning  closely  simulates 
ordinary  non-specific  sores. .  It  often  begins  as  a  chap  or  fissure,  frequently  found 
in  the  median  line,  as  an  aphthous  lesion,  on  an  ulceration  such  as  would  be 
produced  by  the  bum  of  a  cigar  or  of  a  cigarette.     In  the  early  stage  there 


704 


GENITO-URINARY  SURGERY 


Fig.  371. — Chancre  of  the  Hp. 


Fig.  372. — Chancre  of  the  lip. 


PLATE  XIV. 


Chancre  of  lip. 


SYPHILIS 


705 


is  nothing  characteristic  about  these  lesions,  but  in  a  few  days  the  extension 
of  the  erosion  or  ulcer,  with  its  pseudomembranous  covering,  and  the  formation 
of  a  characteristic  and  usually  very  pronounced  and  extensive  induration  indicate 
the  nature  of  the  affection  (Plate  XIV,  Fig.  371).  The  diagnosis  is  made  still 
more  positive  in  the  course  of  one  or  two  weeks  by  enlargement  of  the  sub- 
mental lymph-nodes. 

The  whole  lip  is  generally  congested  and  swollen,  sometimes  reaching  an 
enormous  size  (Fig.  372).  At  times  the  induration  of  lip  chancre  is  so  great 
and  the  ulcerating  process  so  marked  that  on  first  inspection  it  seems  to  be 
malignant.  The  fact  that  chancres  have  been  excised  because  they  were  mistaken 
for  epitheliomata,  thus  entailing  on  a  patient  unnecessary  mutilation,  justifies 
a  tabulation  of  the  points  of  difference  between  the  two  affections,  by  a  con- 
sideration of  which  the  nature  of  each  may  be  correctly  determined. 


Labial  Ephithelioma. 

History. — Sometimes  a  history  of  can- 
cer  in   the   familj-. 

Age. — Occurs  nearly  always  after  middle 
life. 

Sex. — Hardly  ever  affects  females. 

Seat. — Almost  always  involves  lower  Up. 

Local  Symptoms. — An  irregular,  ragged, 
often  painful  sore,  bleeding  easily, 
and  irregularly  indurated.  An  of- 
fensive  discharge. 

Course. — The  sore  develops  very  slowly 
—a  matter  of  months.  The  Ij^mph- 
nodes  are  involved  only  after  sev- 
eral   months. 


Labial  Chancre. 

History. — Sometimes    a    history    of    ex- 
posure  to   syphilitic   inoculation. 
Age. — Occurs  at  any  age. 

Sex. — Affects    males    and    females    differ- 
ently. 
Seat. — 'Involves    either    lip. 
Local   Symptoms. — A    painless    elevated 

sore,  regular  in  outline  with  a  smooth 

surface    and    a    circumscribed,    dense 

induration.      A    scanty,    odorless    dis- 
charge. 
Course. — The    sore    develops    in    a    few 

weeks   at   most,   often   in   from  seven 

to  ten  days.     It  is  followed  in  one  or 

two  weeks  by  subma.xillary  lymphatic 

enlargements,     and    in    from    six    to 

eight  weeks  by  secondary  sj-mptoms. 
Therapeutic  Test. — Mercury  and  arsenic 

cause    the    prompt    disappearance    of 

the   chancre. 
Microscopic  Examination. — The   chancre 

shows  a  small,  round-celled  infiltrate, 

particularly   along   the   course   of   the 

blood-vessels.         Treponemata       found 

by  appropriate   methods. 

Chancre  of  the  Tongue. — The  primary  lesion  of  syphilis  is  less  common 
on  the  tongue  than  on  the  lips.  It  usually  involves  the  anterior  half  of  the 
organ,  and  is  found  on  the  dorsal  surface,  the  sides,  or  the  tip. 

It  commonly  assumes  the  erosive  form,  presenting  an  appearance  almost 
identical  with  that  of  similar  genital  lesions.  There  is  simply  a  painless,  oval, 
or  rounded  superficial  lesion,  with  smooth  surface,  frequently  covered  by  a 
grayish  pseudo-membrane  seated  upon  a  parchment-like  induration  (Figs.  373 
and  374).  It  is  often  as  large  as  a  ten-cent  piece.  The  supra-hyoidean  and 
sometimes  the  submental  lymph-nodes  first  exhibit  the  specific  enlargement. 

The  ulcerative  form  of  lingual  chancre  exhibits  a  deep  lesion,  often  upward 
of  an  inch  in  diameter,  with  sloping  edges,  and  dense,  well-marked  induration. 

45 


Therapeutic  Test. — Mercury  a,nd  ar- 
senic have  no  beneficial  effect  upon 
the    epithelioma. 

Microsopic  Examination. — The  epitheli- 
oma shows  the  pearly  bodies. 


706 


GEXITO-URIXARY  SURGERY 


However  easy  the  diagnosis  may  be  when  the  chancre  is  well  developed,  in 
the  first  stages  lingual  chancres  closely  simulate  non-specific  lesions.  An  early 
diagnosis  is  extremely  important  in  these  cases,  since  failure  to  recognize  the 
syphilitic  nature  of  the  disease  may  result  in  its  transmission  to  healthy  persons. 
If  an  ulceration  apparently  produced  by  carious  teeth,  or  a  papule  arising 
without  given  cause,  fails  to  heal  in  five  or  six  days,  but,  on  the  contrary, 


Fig.  373. — Chancre  of  the  tongue.   (From  the  collection  of  photographs  of   Dr. 
Oeorge  Henry  Fox.; 

enlarges,  becomes  elevated,  is  eroded,  is  covered  with  pseudo-membrane,  and  is 
not  made  better  by  mild  applications,  the  lesion  may  be  looked  on  with  great 
suspicion,  which  will  deepen  into  almost  certainty  with  the  appearance  of  indura- 
tion and  lymphatic  enlargement. 

Chancre  of  the  Tonsils  and  Fauces.— Chancre  is  rare  in  these  regions, 
and  when  observed  is  so  masked  by  concomitant  inflammatory  symptoms  that 


SYPHILIS  707 

diagnosis  is  usually  impossible.  The  lesion  as  described  presents  the  appearance 
of  a  mucous  patch,  which  is  single,  and,  if  it  can  be  palpated  by  one  finger  in 
the  pharynx  and  the  other  external  to  its  walls,  is  found  to  be  indurated. 
There  is  a  history  of  prolonged  sore  throat,  and  in  one  or  two  weeks  the  lymph- 
nodes  at  the  angle  of  the  jaw  enlarge. 


Fig.  374. — Chancre  of  the  tongue. 

Primary  syphilis  of  the  tonsil  is  observed  in  women  much  more  frequently 
than  in  men. 

The  diagnosis  should  be  suggested  by  the  persistence  of  an  irregular,  often 
painful,  ulcer.  The  whole  tonsil  is  swollen;  the  submaxillary  and  upper  deep 
cervical  lymph-nodes  enlarge.  The  diagnosis,  which  can  be  made  quickly  with 
the  microscope,  is  generally  made  only  after  the  appearance  of  characteristic 
secondary  lesions. 

Chancre  of  the  Breast 

The  lesion  is  usually  caused  by  a  syphilitic  infant  nursed  by  a  healthy 
woman:  hence  it  is  in  women  that  it  is  nearly  always  observed,  though  a  few 
cases  have  been  reported  in  men,  with  a  different  etiology. 

The  sore  may  appear  either  about  or  upon  the  nipple,  or  upon  the  skin 
covering  the  mammary  gland.  In  the  latter  case  it  usually  exhibits  the  char- 
acteristic features  of  chancre  as  found  on  the  genitalia,  being  commonly  of  the 
erosive  or  the  ulcerative  type  and  rarely  offering  diagnostic  difficulties. 

When  the  lesion  is  situated  on  the  nipple  or  at  its  base,  the  sore  very  closely 
simulates  non-specific  affections,  such  as  simple  fissure,  mechanical  erosion  or 
ulcer,  or  even  beginning  eczema.  If,  however,  a  lesion  so  apparently  simple, 
instead  of  healing  under  treatment,  slowly  extends,  if  it  is  accompanied  by  little 
or  no  pain,  if  it  gives  a  scanty,  blood-stained  discharge  which  has  a  tendency  to 
crust,  and,  most  important  of  all,  if  it  exhibits  distinct  induration  and  painless, 
non-inflammatory  lymphatic  enlargement  in  the  axilla,  the  diagnosis  of  chancre 
can  be  made  with  some  certainty. 


708  GENITO-URINARY  SURGERY 

Suspicious  lesions  in  a  nursing  woman  should  at  once  suggest  an  examination 
of  the  child  she  suckles.  Secondary  lesions  in  the  mouth  of  the  latter  would 
constitute  alm.ost  positive  e\adence  as  to  the  s\'phiHtic  nature  of  the  breast  lesions 
in  the  woman,  provided  she  is  not  the  motner  of  the  diseased  child  (Colles's 
immimity) . 

Chancres  of  the  Anal  Region 

Chancres  of  the  anus  are  much  more  common  in  women  than  in  men, 
from  the  fact  that  in  the  dorsal  decubitus  the  vaginal  discharges  flow  downward 
over  the  perineum  and  the  anus  and  thus  inoculate  the  cracks  or  abrasions 
which  may  exist  in  those  regions. 

The  sore  is  usually  placed  at  the  anal  margin,  in  one  of  the  muco-cutaneous 
folds  or  puckerings  incident  to  the  normal  contraction  of  the  external  sphincter. 
The  ulceration  often  follows  the  line  of  these  folds,  thus  producing  an  elongated 
or  linear  lesion;  this  becomes  indurated,  gives  a  scanty  discharge,  is  refractory 
to  local  treatment,  and  is  generally  followed  by  characteristic  enlargement  of  the 
inguinal  lymph-nodes. 

In  place  of  the  indurated  linear  ulcer,  an  anal  chancre  may  appear  as  an 
excoriated  papule,  or,  more  rarely,  as  a  tj^ical  cup-shaped,  densely  indurated, 
ulcerating  chancre. 

From  the  appearance  of  the  anal  lesion  it  is  sometimes  very  difficult  to  deter- 
mine whether  it  is  a  fissure,  or  a  simple  ulcer,  or  the  primary  sore  of  s^-philis. 
The  slow  (two  to  four  weeks),  progressive  development  of  the  chancre  will 
indicate  the  specific  nature  of  the  affection,  even  before  induration  and  lymphatic 
involvement  make  the  diagnosis  almost  positive. 

Chancres  of  the  rectum  are  exceedingly  rare.  A  single,  apparently  causeless, 
refractory  (week's)  ulcer  should  suggest  syphilis. 

Chancres  of  the  Extremities 

Chancre  is  occasionally  obsen.'ed  on  the  thighs,  the  anterior  surface  in  men 
and  the  posterior  surface  in  women  being  the  regions  of  preference,  on  the 
antero-lateral  surfaces  of  the  forearm  in  both  sexes,  and  particularly  on  the 
fingers  at  the  margins  of  the  nails.  Occasionally  it  develops  over  a  knuckle, 
inoculated  through  a  wound  caused  b}'  a  blow  on  the  teeth  of  a  syphilitic. 
Except  on  the  fingers,  the  chancre  develops  in  a  characteristic  manner  and 
offers  no  special  diagnosis  difficulties. 

Digital  chancres  commonly  appear  at  the  edges  or  the  base  of  the  nail, 
starting  as  erosions,  papules,  or  pustules,  becoming  indurated,  elevated,  and 
ulcerated,  being  accompanied  by  much  swelling  of  the  surrounding  finger-pulp, 
and  presenting  the  appearance  of  an  ulcerating  felon  (Fig.  375). 

The  chancre,  however,  develops  slowly,  is  not  extremely  painful,  discharges 
but  little,  is  not  favorably  influenced  by  local  treatment,  and  is  shortly  followed 
by  epitrochlear  and  axillar\'-  Hmiphatic  enlargement.  \\'Tien  the  lesion  involves 
the  ring  or  the  little  finger,  the  node  at  the  elbow,  if  present,  is  enlarged;  the 
lymphatics  from  the  thumb  and  from  the  index  and  middle  fingers  pass  directly 
to  the  axillary  nodes. 


SYPHILIS 


709 


Sometimes  the  chancre  may  develop  so  insidiously  and  may  form  so  in- 
significant a  lesion,  simply  a  small  indurated  papule,  that  even  the  patient's 
attention  is  not  directed  to  it,  and  he  has  no  suspicion  of  having  acquired 
syphilis  till  the  secondary  lesions  appear. 

The  early  diagnosis  of  digital  chancre  is  a  matter  of  special  importance  to 
doctors  and  nurses,  who  form  the  class  in  which  digital  chancres  are  observed. 
Any  painless  lesion  about  the  fingers  giving  a  scanty  discharge,  steadily  enlarging 
in  spite  of  treatment,  and  becoming  distinctly  hard,  should  excite  suspicion,  and 
should  lead  to  a  careful  examination  for  the  treponema. 

Vaccination   Chancre. — When  human  lymph   has  been  employed,   this 


Fig.  375. — Chancre  of  finger.     Nine  weeks'  duration. 


accident  has  occurred  many  times.  If  the  vaccination  takes,  the  pustule  may 
run  the  typical  course,  and  may  be  healed  before  evidences  of  the  chancre 
appear.  More  commonly  the  healing  of  the  ulcer  resulting  from  the  vaccinal 
suppuration  is  delayed;  it  presents  a  smooth  surface,  gives  a  scanty  discharge, 
is  unattended  by  pain,  and  characteristic  induration  develops.  The  associated 
lymph-nodes  are  enlarged,  and  secondary  symptoms  follow. 

If  the  vaccination  does  not  take,  there  may  be  no  sign  of  trouble  for 
fifteen  to  thirty  days.  Then  an  indurated  papule  is  formed,  which  slowly 
ulcerates  and  offers  all  the  peculiarities  of  erosive  or  ulcerative  chancre.  Some- 
times the  vaccination  ulcer  becomes  acutely  inflamed,  even  phagedaenic,  the 
inflammatory  symptoms  thus  masking  the  syphilitic  nature  of  the  lesion:  simple 
vaccinal  phagedsenism  may,  however,  present  some  of  the  features  of  an 
inflamed  chancre. 


710  GENITO-URINARY  SURGERY 

THE  PROGNOSIS  OF  CHANCRE 

Usually  in  three  or  four  weeks,  sometimes  in  as  many  months,  the  chancres 
become  cicatrized,  the  induration  disappears,  and  there  is  left  a  brownish  scar, 
which  may  persist  for  years.  This  scar  may  retain  its  pigmentation  as  long  as 
it  remains  perceptible;   more  commonly  it  becomes  white. 

Heahng  of  the  chancre  will  take  place  spontaneously,  but  will  be  greatly 
accelerated  by  specific  treatment.  Even  in  extensive  ulcerating  chancres,  such 
as  are  observed  on  the  cheeks  or  the  lips,  for  instance,  there  is  almost  no 
ultimate  deformity,  since  the  destruction  of  tissue  is  mainly  at  the  expense  of 
the  syphilitic  infiltrate.  If  the  chancre  is  attacked  by  phagedaena — which  is 
rare — and  if  the  sloughing  process  destroys  the  induration  and  passes  wide  of 
its  limits,  there  may  be  resultant  cicatricial  deformity,  but  this  will  be  due  not 
to  the  specific  poison,  but  to  the  destructive  influence  of  other  microbes. 

Chancre  of  the  conjunctiva  may  give  rise  to  grave  ophthalmia. 

Chancre  of  the  tongue  or  of  the  fauces  may,  through  interference  with 
mastication  or  deglutition,  cause  great  debility,  and  chancre  of  the  urethra  is 
frequently  followed  by  stricture. 

The  prognosis  of  syphilitic  chancre  considered  as  a  local  disease  is,  then, 
almost  uniformly  favorable.  As  to  any  relation  existing  between  the  source 
of  contagion,  the  chancre,  and  the  constitutional  disease  of  which  it  is  the 
precursor,  the  following  clinical  facts  seem  well  established: 

1.  It  is  impossible  to  predict  the  form  of  chancre  from  the  character  of  the 
source  of  infection.  It  is  well  known  that  the  most  widely  differing  forms  of 
initial  lesion  may  be  acquired  from  the  same  individual. 

2.  The  severity  of  the  constitutional  disease  bears  no  relation  to  the  form 
of  the  initial  lesion.  A  dry  papule  may  be  followed  by  severe  secondary  symp- 
tom.s,  while  an  ulcerating  chancre  may  precede  a  very  slight  form  of  consti- 
tutional involvement. 

3.  A  short  primary  incubation  has  been  shown  experimentally  to  be  indica- 
tive of  a  strong  tissue  resistance  against  the  disease. 

4.  The  amount  of  lymphatic  involvement  is  as  uncertain  a  prognostic  guide, 
in  regard  to  the  severity  of  the  constitutional  disease,  as  is  the  type  of  chancre. 

The  treatment  of  chancre  is  described  under  the  treatment  of  syphilis  (see 
pp.  863  and  887). 

Primary  Lymphatic  Involvement 

Coincident  with  the  development  of  the  chancre  there  is  a  marked  alteration 
in  the  associated  lymphatic  vessels  {lymphangitis)  and  nodes  {lymphadenitis 
or  bubo). 

Syphilitic  Lymphangitis. — In  about  twenty  per  cent,  of  genital  chancres 
there  develops  usually  within  the  first  week,  and  before  the  lymph-nodes  are 
involved,  a  painless,  often  beaded  hardening  of  the  lymphatic  vessels  of  the 
dorsum  of  the  penis.  They  form  a  cord  about  the  size  of  a  match-stick,  and 
may  be  felt  starting  from  the  region  of  the  chancre  and  running  up  as  far  as 
the  inguinal  glands,  though  the  hardening  does  not  often  extend  more  than  two 
or  three  inches  along  the  back  of  the  penis.  Unless  there  is  mixed  infection, 
the  skin  over  these  lymphatic  vessels  does  not  become  discolored  or  adherent; 
except  the  induration,  there  are  no  signs  of  inflammation.  There  may  be  sev- 
eral of  these  indurated  lymphatic  vessels,  forming  small  distinct  cords. 


SYPHILIS  711 

The  specific  lymphangitis  usually  subsides  with  the  induration  of  the  chancre 
— that  is,  within  tnree  to  five  weeKs;  though,  hke  the  latter,  it  may  last  for 
several  months. 

The  lymphangitis  accompanying  extragenital  chancres  and  genital  chancres 
of  women  can  rarely  be  detected,  owing  to  the  less  accessible  position  of  the 
involved  lymphatic  vessels. 

Syphilitic  Lymphadenitis  or  Bubo. — The  syphilitic  bubo  is,  after  the 
chancrous  induration,  the  most  characteristic  and  constant  feature  of  primary 
syphilis.  As  commonly  used,  the  term  syphilitic  bubo  is  applied  only  to  those 
lymph-nodes  with  which  the  lymphatic  vessels  from  the  chancre  directly  com- 
municate. In  about  a  week  from  the  appearance  of  the  chancre  these  nodes 
undergo  a  painless  enlargement.  Since  chancres  are  usually  placed  upon  the 
genitalia,  the  inguinal  nodes  are  the  ones  commonly  affected.  In  accordance 
with  the  seat  of  chancre,  the  bubo  will  be  placed  as  follows: 

Genital  and  perigenital  chancres  (including  those  of  the  perineum  and  anus) 
involve  the  inguinal  nodes;  chancres  of  the  lip  and  chin  involve  the  submaxillary 
nodes;  chancres  of  the  tongue  involve  the  suprahyoid  or  submaxillary  nodes; 
chancres  of  the  eyelid  involve  the  preauricular  nodes;  chancres  of  the  fingers 
involve  the  epitrochlear  or  axillary  nodes;  chancres  of  the  breast  involve  the 
axillary  nodes. 

In  genital  chancre  the  node  first  affected  is  usually  the  nearest  one  of  the 
chain  on  the  affected  side,  though  when  the  lesion  is  situated  upon  the  side  of 
the  fraenum  a  node  of  the  opposite  side  may  first  enlarge.  Subsequently,  one 
after  the  other,  several  of  the  nodes  or  the  entire  chain  become  hypertrophied. 
This  commonly  takes  place  in  both  groins,  though  exceptionally  it  is  limited  to 
one  side.  On  examination  the  nodes  are  felt,  each  distinct,  hard,  almond- 
shaped,  painless,  and  freely  movable. 

There  are  often  one  large  node  and  a  group  of  from  three  to  five  smaller 
ones,  each  about  the  same  size.  Sometimes  but  a  single  node  is  enlarged;  this 
is  particularly  the  case  with  extragenital  chancres,  such  as  those  of  the  lip.  The 
enlargement  is  never  very  great,  the  ganglia  rarely  exceeding  the  size  of  a 
marble.  The  group  of  typically  indurated  nodes  of  the  groin  has  been  termed 
the  "  plei'ade  ganglionnaire." 

Suppuration  occurs  in  these  nodes  only  as  a  result  of  mixed  infection,  the  pyo- 
genic microbes  gaining  access  through  the  surface  break  caused  by  the  chancre. 

In  very  exceptional  eases  chancre  is  not  accompanied  by  syphiHtic  bubo. 

Diagnosis. — Since  lymphatic  vessels  and  nodes  may  be  enlarged  as  a  con- 
sequence of  simple  inflammation,  and  since  the  S5^hilitic  bubo  is  one  of  the 
important  means  of  diagnosing  chancre,  it  is  necessary  to  bear  in  mind  the  points 
of  difference  between  syphilitic  and  simple  inflammatory  involvement  of  the 
lymphatics.    These  points  of  difference  are  as  follows: 

Syphilitic   Lymphangitis.  Inflammatory    Lymphangitis. 

Cause. — Always  a  chancre.  Cause. — Chancroids,    herpes,     or    other 

non-specific   lesion. 

Symptoms. — A  hard,   painless   cord,   un-       Symptoms. — A  cord  not  so  hard  nor  so 

accompanied  by  heat,  redness,  or  ten-  sharply    circumscribed;     often    painful, 

derness.       Erection    painless.      Little  especially    on    erection;     tender    and 

or  no  oedema.  accompanied    by    heat,    redness,    and 

oedema   of   the    overlying   skin. 


712  GENITO-URINARY  SURGERY 


Syphilitic  Lymphangitis.  Inflammatory  Lymphangitis. 

Termination. — Undergoes  resolution.    Is       Termination.  —  Undergoes     suppuration 
uninfluenced  by  local  treatment.  or    resolution.      Local    treatment    ef- 

fective. 
Syphilitic   Bubo.  Inflammatory  Bubo. 

Cause. — Always    chancre.  Cause. — Chancroid,    herpes,    balanopos- 

thitis,    gonorrhoea,    or    any    non-spe- 
Number. — Several     nodes,     usually     in  cific    lesion. 

both  groins.  Number. — One   node   implicated.      Rarely 

Time     of     Appearance. — Shortly     after         bilateral. 

chancre;  about  one  wreck.  Time     of     Appearance. — At     any     time 

Symptoms. — Small,     indolent,     painless,  during  the  existence  of  a  lesion. 

movable,    non-inflammatory    tumors.       Symptoms. — A      large,      tender,      painful,. 

non-adherent  to  the  skin,  and  of  car-  acutely  inflamed  tumor,  adherent   to- 

tilaginous  hardness.  the    skin,    and    causing    redness    and 

heat  of  the  latter.     The  hardness  is 
Termination. — Resolution.  that    of    inflammation. 

Treatment. — Local      remedies      without       Termination. — Frequently  suppuration. 

effect.      General   mercurial   treatment       Treatment. — Local    treatment    curative; 

hastens  resolution.  general  mercurial   treatment  useless. 

The  diagnosis  of  syphilitic  buboes  from  the  lymphatic  enlargement  so  fre- 
quently noted  in  strumous  patients  must  depend  entirely  on  the  history  of  the 
case  and  the  development  of  the  tumors.  The  strumous  adenomata  neither 
increase  nor  decrease  in  size  unless  they  become  inflamed,  in  which  case  they 
break  down  and  suppurate.  A  tuberculous  family  history,  together  with  other 
signs  of  struma  about  the  patient,  can  often  be  elicited;  there  is  no  progressive 
involvement  first  of  the  lymphatics  anatomically  connected  with  the  seat  of  the 
sore,  then  of  all  the  lymphatics  accessible  to  the  examining  fingers;  and  finally 
resolution  does  not  partly  or  wholly  take  place  in  the  majority  of  cases  in 
from  two  to  six  weeks,  nor  is  this  resolution  in  the  slightest  degree  quickened 
by  the  administration  of  mercury. 

Treatment. — Syphilitic  infiltration  of  the  lymphatic  vessels  and  nodes 
usually  requires  no  treatment,  subsiding  spontaneously  soon  after  the  dis- 
appearance of  the  induration  of  the  chancre,  though  the  enlargement  of  the 
lymphatic  nodes  may  persist  for  months,  or,  exceptionally,  for  many  years.  The 
administration  of  mercurj^,  when  the  diagnosis  has  become  so  certain  that  its 
use  is  justifiable,  causes  a  rapid  disappearance  of  the  specific  infiltrate.  In 
cases  complicated  by  acute  inflammation  and  suppuration  the  treatment  is  the 
same  as  that  appropriate  to  chancroidal  lymphangitis  and  bubo. 

THE  PERIOD  OF  SECONDARY  INCUBATION 
The  period  between  the  appearance  of  chancre  and  tjie  development  of 
secondary  lesions  varies  from  two  weeks  to  three,  or  even  six,  months.     The 
average  time,  however,  is  forty-two  days.     The  primary  lesion  often  remains 
during  the  whole  of  this  period. 

The  disease,  so  far  as  constitutional  symptoms  are  concerned,  is  apparently 
quiescent.  In  reality  the  virus  is  becoming  disseminated  through  the  entire 
system,  first  manifesting  its  effect  upon  the  accessible  lymphatic  nodes  not 
anatomically  connected  with  the  primary  sore.  Enlargement  of  these  nodes 
usually  constitutes  the  first  secondary  symptom,  and  is,  except  changes  in  the 
blood,  the  earliest  positive  sign  of  constitutional  S3^hilis. 


CHAPTER  XXXV 

SYPHILIS— (Continued) 

Constitutional  syphilis  includes  the  period  of  secondary  symptoms,  the- 
intermediate  period,  and  the  period  of  tertiary  symptoms. 

The  period  of  secondary  symptoms  is  characterized  by: — 1.  Alterations  of 
the  blood.  2.  General  lymphatic  enlargement.  3.  Moderate  fever,  the  tempera- 
ture reaching  100°  to  101°  F,  in  the  evening;  often  associated  with  malaise  and 
anorexia.  4.  Muscular  and  articular  pains,  about  the  chest,  back,  and  upper 
extremities,  usually  moderate  in  severity,  but  sometimes  very  severe.  5.  Alo- 
pecia, involving  the  hairy  surfaces  of  the  entire  body,  and  causing  ragged  and 
irregular  bald  spots  very  unlike  those  incident  to  the  ordinary  atrophy  of  hair- 
follicles.    6.  Eruptions  of  the  skin  and  the  mucous  membranes. 

Frequently  associated  with  these  manifestations  are  symptoms  dependent 
upon  involvement  of  the  eyes,  the  nervous  system,  the  bones  and  periosteum,  the 
testicle,  and  the  liver  and  other  glands. 

The  term  secondary  syphilis  has  been  applied  to  those  lesions  which  appear 
during  the  first  two  or  three  years  of  the  constitutional  disease,  and  which  are- 
for  the  most  part  superficial;  yet  it  must  be  remembered  that  secondary  symp- 
toms may  never  appear,  the  first  manifestation  of  constitutional  involvement, 
occurring  after  one  or  two  years  in  the  deeper  ulcerative  form  of  surface  lesions, 
or  in  the  more  serious  visceral  complications  which  characterize  tertiary  or 
late  syphilis.  When  such  deep  ulcerative  lesions  are  noted  during  the  period 
when  secondary  symptoms  should  appear — that  is,  in  the  first  few  months  of 
the  attack — the  disease  is  termed  malignant  syphilis.  Conversely,  during  the 
period  when  tertiary  eruptions  and  visceral  complications  ordinarily  appear,  and 
when  such  lesions  are  actually  present,  lesions  particularly  characteristic  of 
secondary  syphilis  may  develop,  such,  for  instance,  as  papules  of  the  skin  or 
mucous  patches  of  the  mouth.  Irregular  syphilis  is  a  term  applied  to  cases  thus 
differing  in  course  from  those  ordinarily  observed. 

It  will  be  remembered  that  the  diagnosis  of  syphilis  can  be  made  clinically 
with  absolute  surety  only  when  one  or  more  of  the  constitutional  symptoms 
develop.  One  of  the  first  of  these  symptoms,  and  the  one  upon  which  diagnosis 
is  usually  founded,  is  enlargement  of  lymphatic  glands  at  a  distance  from  the 
chancre.  Unless  treatment  be  started  at  once,  there  will  usually  develop  in  a 
few  days  following  this  enlargement  the  secondary  symptoms  already  men- 
tioned— namely,  fever,  osteocopic  pains,  skin  eruptions,  mucous  patches,  sore 
throat,  falling  of  the  hair  in  patches,  and  at  times  iritis,  orchitis,  or  jaundice. 

Alteration  in  the  Blood. — If  systematic  observations  of  the  blood  be 
made,  there  will  be  found  a  diminution  in  the  haemoglobin  percentage  and  red 
corpuscles,  with  slight  leucocytosis.  These  blood  changes  are  the  first  sign  of 
constitutional  syphilis,  preceding  lymphatic  enlargement  by  two  or  three  weeks; 
they  become  more  marked  with  the  advent  of  fever  and  on  the  appearance  of 
the  eruption. 

713 


714  GENITO-URINARY  SURGERY 

The  appearance  in  the  blood  of  a  substance  known  as  "  Wassermann  body  " 
must  also  be  noted  as  one  of  the  early  symptoms  of  syphilis.  Just  what  this 
substance  really  is  we  do  not  know,  but  it  is  probably  of  a  lipoid  character, 
and  is  certainly  not  a  true  syphilitic  antibody.  Its  presence  is  recognized  by 
means  of  the  complement- fixation  test  bearing  Wassermann's  name  (see  Chap- 
ter XLIII). 

Enlargement  of  Lymphatic  Glands  not  anatomically  connected 
WITH  the  Chancre. — The  indolent  enlargement  which  probably  involves  to 
some  extent  all  the  lymphatic  nodes  of  the  economy,  and  which  becomes  appar- 
ent to  the  touch  in  certain  accessible  regions  about  the  sixth  week  from  the 
appearance  of  the  chancre,  must  not  be  confounded  -with  the  syphilitic  buboes 
which  develop  in  about  a  week  in  the  group  of  nodes  anatomically  nearest  to 
the  chancre.  This  late  lymphatic  enlargement  when  characteristically  de- 
veloped is  pathognomonic  of  S3^hilis.  While  probably  all  the  lymphatic  nodes 
are  involved,  those  in  the  post-cervical  regions  and  the  epitrochlear  node,  lying 
above  and  in  front  of  the  internal  condyle  of  the  humerus,  are  most  prone  to 
exhibit  the  indolent  cartilaginous,  painless,  non-infiammatory  enlargement  so 
characteristic  of  developing  secondary  syphilis.  The  submaxillary,  the  anterior 
cervical  group,  the  axillary,  in  fact,  all  the  superficial  nodes,  may  show  the 
specific  induration,  but  rare  in  so  characteristic  a  manner  as  those  in  the  two 
regions  named.    The  tumors  formed  vary  from  the  size  of  a  pea  to  a  chestnut. 

The  post-cervical  chain  passing  downward  from  the  occipital  bone  along 
the  outer  edge  of  the  trapezius  muscle  is,  in  cleanly  people  at  least,  rarely 
enlarged  from  causes  other  than  syphilis;  thus  painless,  hard,  indolent  infiltration 
of  these  nodes  would  be  far  stronger  evidence  of  specific  disease  than  a  similar 
condition  noted  in  the  sub-maxillary  and  anterior  cervical  group,  which,  o%ving 
to  the  presence  of  catarrhal  and  inflammatory  affections  of  the  throat  from  which 
they  receive  lymph,  are  found  enlarged  in  perhaps  the  majority  of  people. 
For  a  similar  reason  characteristically  enlarged  epithrochlear  nodes — that  is, 
those  above  and  in  front  of  the  internal  cond5de — constitute  presumptive  evi- 
dence of  syphilis. 

In  syphilitic  lymphatic  nodes  the  follicles  of  the  delicate  reticulated  tissues 
are  hypertrophied,  and  give  rise  to  small  lobulated  projections  upon  the  surface 
when  the  capsule  is  removed.  The  lymph-spaces  exhibit  a  cellular  infiltration, 
and  the  fibrous  tissues  separating  the  alveoli  are  thickened.  Frequently  these 
nodes  remain  more  or  less  hypertrophied  not  only  during  the  period  of  second- 
ary lesions,  but  also  long  after  the  syphilides  have  disappeared. 

Although  there  is  no  clearly  established  relation  between  the  extent  of 
the  lymphatic  lesion  and  the  severity  of  other  secondary  symptoms  of  syphilis, 
early  and  well-marked  lymphatic  involvement  frequently  has  been  noted  in 
attacks  of  more  than  usual  severity. 

Syphilitic  Fever. — About  the  time  of  lymphatic  enlargement,  and  coin- 
cident with  the  earliest  eruption,  or  preceding  it,  fever  develops,  associated 
with  pallor,  weakness,  general  malaise,  headache,  coated  tongue,  anorexia,  and 
muscular  or  arthritic  pains.  The  temperature  rarely  rises  above  102°  F..  and 
the  pulse  is  not  markedly  affected.  In  many  patients  the  fever  is  either  absent 
or  so  slightly  marked  that  it  is  not  noticed.     It  rarely  becomes  so  severe  as 


SYPHILIS  715 

to  oblige  the  patient  to  keep  to  his  bed.  Exceptionally  it  assumes  a  malarial 
type,  being  characterized  by  irregular  paroxysms  of  chills,  fever,  and  sweat, 
but  differs  from  malaria  in  the  irregularity  of  the  paroxysms  and  in  the  fact 
that  quinine  is  utterly  without  effect  in  controlling  it,  while  mercury  is  curative. 

\^'hen  the  fever  is  continued  and  moderate  in  severity,  and  associated  with 
depression  of  spirits,  pallor,  headache,  and  general  debility,  it  may  strongly 
suggest  typhoid.  If  continued  and  of  high  grade,  running  to  104^  or  105"^  F. 
and  associated  with  evident  osteocopic  pains,  it  may  lead  to  a  suspicion  of  de- 
veloping eruptive  fever.  If  associated  with  an  outbreak  of  pustular  syphiloderm, 
such  as  exceptionally  appears  as  an  early  skin  lesion,  the  diagnosis  from  small- 
pox may  be  exceedingly  difficult. 

The  involvement  of  the  joints  in  early  syphilis  may,  if  associated  with 
syphilitic  fever,  make  the  diagnosis  of  the  latter  from  rheumatic  fever  a  matter 
of  impossibility  till  other  symptoms  of  syphilis  develop. 

Diagnosis. — In  making  a  diagnosis  of  syphilitic  fever,  the  history  of  a 
preceding  chancre,  the  presence  of  lymphatic  enlargements  are,  of  course,  mat- 
ters of  prime  importance.  In  addition  to  the  history  and  the  Wassermann 
reaction,  it  is  to  be  noted  that  syphilitic  fever  is  frequently  associated  with 
a  clean  tongue,  good  digestion,  normal  condition  of  the  bowels,  and  an  absence 
of  the  special  diagnosistic  features  which  characterize  each  of  the  fevers  with 
which  it  may  be  confounded,  as,  for  instance,  the  plasmodia  and  enlarged  spleen 
of  malaria,  the  tympany  and  spots  of  typhoid,  and  the  crisis  of  variola. 

It  commonly  subsides  shortly  after  the  appearance  of  the  eruption.  When 
it  is  continuous  in  type,  is  pronounced,  and  lasts  for  some  time,  the  probability 
is  that  the  attack  of  syphilis  will  be  unusually  severe  and  prolonged.  In  ex- 
ceptional cases  it  does  not  appear  till  after  the  eruption  has  developed.  It  is 
mostly  in  women  that  the  severe  forms  of  continuous  syphilitic  fever  are 
observed. 

Syphilitic  Neuralgia. — Coincidently  with  the  syphilitic  fever  and  con- 
stituting one  of  its  symptoms,  but  also  developing  in  the  absence  of  evident 
fever,  or  sometimes  preceding  it,  there  may  be  dull  pain,  which  is  commonly 
neuralgic  and  shifting  in  character,  and  is  felt  mostly  about  the  back  of  the 
neck,  the  back,  and  the  shoulders,  though  it  may  be  localized  in  any  portion 
of  the  fibro-osseous  system.  This  pain  is  most  apt  to  be  noticed  at  night; 
when  continuous  and  severe  there  are  usually  nocturnal  exacerbations.  It 
occasionally  attacks  one  or  more  joints,  and  may  be  accompanied  by  effusion 
and  fixation;  or  it  may  assume  a  distinctly  neuralgic  type,  simulating  pleuro- 
dynia or  other  form  of  localized  pain.  Headaches,  with  nocturnal  exacer- 
bations, and  sometimes  associated  with  vertigo  and  nausea,  point  to  meningeal 
congestion. 

Frequently  the  pains  are  osteocopic  (bone-breaking)  in  character,  and  are 
accompanied  by  marked  tenderness  over  certain  bones,  particularly  the  middle 
third  of  the  ribs  and  the  lower  third  of  the  sternum.  This  is  so  often  noted 
that  some  diagnostic  value  is  given  to  the  presence  of  pain  on  moderate  pressure 
over  these  bones.  These  osteocopic  pains  are  explained  (Jullien)  on  the  ground 
that  the  medulla  of  the  bone  takes  part  in  the  general  lymphatic  enlargement, 
thus  occasioning  pressure  upon   the  nerves.     Painful   nodular   swellings  over 


716  GENITO-URINARY  SURGERY 

the  frontal  and  parietal  bones,  or  over  the  long  bones,  are  also  noted  at  times. 

In  doubtful  cases  rheumatoid,  neuralgic,  and  osteocopic  pains,  either  singly 
or  associated,  are  of  great  value  in  deciding  for  or  against  the  presence  of 
s\^hilis.  In  some  instances  lymphatic  enlargement  and  syphilitic  pains  may  be 
the  only  symptoms  which  develop,  fever  being  absent. 

Among  the  symptoms  which  exceptionally  precede  alopecia  and  the  secondary 
eruption,  jaundice,  albuminuria,  ravenous  appetite  or  bulimia,  alteration  in 
the  sensibility  of  the  skin,  exaggerated  reflexes,  and  enlargement  of  the  spleen 
have  been  observed. 

Syphilitic  Eruptions  of  the  Skin  and  the  Mucous  Membranes. — The 
s\TDhilides,  or  eruptions  of  the  skin,  commonly  appear  a  few  days  after  the 
general  lymphatic  enlargement,  though  they  are  occasionally  the  first  manifesta- 
tions of  constitutional  disease.  They  are  usually  found  about  the  forty-second 
day  after  the  chancre.  Exceptionally  they  have  been  seen  within  two  weeks. 
On  the  other  hand,  they  may  not  develop  for  four  or  five  months,  or  in  some 
few  cases  secondar}^  syphilis  may  never  appear,  tertiary  lesions  first  proving 
conclusively  that  a  genital  sore  was  a  chancre.  This  is  especially  liable  to  be 
the  case  if  mercury  has  been  given  before  the  appearance  of  secondary  symptoms. 

Cutaneous  and  mucous  syphilides  are  more  superficial  in  the  early  stages 
of  the  constitutional  disease;  as  it  grows  older  these  lesions  become  deeper. 

Thus  the  sj^hilides  of  the  first  period  of  secondary  syphilis  are  due  to  a 
local  hyperaemia  and  slight  cell-infiltrate,  affecting  only  the  epidermic  and 
papillary  layers  of  the  skin  and  producing  erythematous,  macular,  and  papular 
lesions.  These  heal  \^dthout  leaving  scars.  The  older  sj^^hilides  belonging  to 
the  late  secondary  and  the  tertiary  period  not  only  affect  the  epiderm  and  the 
papillary  layer,  but  involve  also  the  true  derm  and  even  the  subdermic  tissues, 
appearing  as  pustules  and  tubercles,  which  are  often  destructive  and  are  fol- 
lowed by  cicatrices. 

These,  lesions  are  due  to  a  cell-infiltrate  much  like  that  of  granulation-tissue, 
except  that  it  is  not  nearly  so  vascular. 

The  syphilides  ma}'',  so  far  as  the  lesions  are  concerned,  mimic  with  absolute 
fidelity  many  of  the  well-known  skin  diseases;  there  are,  however,  certain  char- 
acteristics of  the  eruption,  taken  as  a  whole,  which  will  generally  make  a  correct 
diagnosis  possible. 

The  general  features  of  secondary  syphilitic  eruptions  are  as  follows: 

1.  The  lesions  develop  slowly,  are  painless,  and  do  not  itch. 

2.  They  are  rounded  in  form  and  grouping,  and  tend  to  scale. 

3.  They  are  of  a  copper  or  raw-ham  color. 

4.  They  are  symmetrical. 

5.  They  are  polymorphous. 

6.  They  are  superficial. 

7.  They  yield  to  specific  treatment. 

The  later  eruptions  of  the  secondary  period — that  is,  those  occurring  after 
the  first  year — and  those  of  the  intermediary  and  tertiary  periods  exhibit  the 
follo\\ang  characteristics: 

1.  They  are  rounded  in  form  and  circinate  in  grouping.  This  is  particularly 
well  marked. 


SYPHILIS  717 

2.  The  lesions  do  not  appear  as  a  general  eruption,  but  are  grouped  upon 
certain  regions  of  the  body. 

3.  They  are  deep,  often  involving  the  whole  thickness  of  the  skin  .and  the 
subcutaneous  tissue. 

4.  If  dry,  they  are  covered  with  a  thin  layer  of  gray,  slightly  adherent  scales. 

5.  If  ulcerating,  they  form  punched-out,  chronic  ulcers,  often  covered  with 
raised,  thick,  greenish-black,  adherent  crusts. 

6.  They  are  accompanied. by  very  slight  subjective  symptoms. 

When  a  general  eruption  first  appearing  on  the  chest  and  abdomen  presents 
these  features  after  full  development,  it  can  certainly  be  judged  syphilitic  in 
its  nature.  Frequently,  however,  the  syphilide  will  depart  in  one  or  more  points 
from  the  type  to  which  it  should  theoretically  correspond. 

The  absence  of  subjective  symptoms — that  is,  freedom  from  pain  and  from 
itching— is  a  rule  which  has  but  few  exceptions,  if  eruptions  on  the  scalp  and 
the  hairy  parts  of  the  body  are  excluded.  In  these  regions  itching  is  very 
common.  On  the  body  and  extremities  the  eruption  is  often  not  noted  by  the 
patient  till  the  physician  calls  attention  to  it;  or  the  patient  becomes  aware  of 
it  only  because  he  has  noticed  it  while  dressing  or  bathing. 

Exceptionally  the  itching  is  severe  and  harassing;  this  may  arise  from  the 
specific  eruption,  but  commonly  it  is  found  to  be  dependent  upon  an  intercurrent 
condition,  such  as  urticaria  or  prurigo  or  the  presence  of  pediculi. 

The  rounded  form  and  grouping  of  the  syphilides  are  usually  fairly  well 
marked,  though  individual  lesions  widely  depart  from  this  type.  The  circinate 
grouping  is  much  more  pronounced  in  the  late  secondary  and  in  the  tertiary 
lesions;  indeed,  it  is  a  striking  feature  of  the  eruption.  In  the  early  secondary 
lesions,  particularly  in  roseola,  this  grouping  is  rarely  so  conspicuous  as  to  be 
noticeable  till  it  is  carefully  searched  for. 

The  raw-ham  or  copper  color  of  the  eruption  is  not  pronounced  at  first. 
The  early  erythema  is  usually  a  dusky  red,  though  it  may  present  the  rosy-red 
hue  of  simple  erythema.  As  the  lesions  develop,  a  certain  amount  of  skin  pig- 
mentation takes  place,  the  erythematous  patches  no  longer  disappearing  entirely 
on  pressure,  but  leaving  a  dark  stain.  The  macules  and  papules  become  still 
more  dusky,  like  raw  ham,  or  even  present  a  distinct  coppery  hue.  This  is 
fairly  constant,  but  is  not  characteristic  till  the  lesion  has  persisted  at  least  some 
days.  A  similar  coloration,  together  with  absence  of  itching,  is  sometimes 
observed  in  the  skin  eruptions  of  gouty  and  rheumatic  subjects.  This  pigmenta- 
tion may  last  for  years;  usually  it  disappears  in  a  few  months.  The  epidermic 
layer  of  the  skin  suffers  by  reason  of  the  interference  with  its  nutrition  caused 
by  the  cell-exudation  in  the  papillary  layer  beneath  it.  Most  syphilides,  there- 
fore, tend  to  become  squamous. 

The  symmetrical  development  of  the  secondary  syphilides  is  an  almost  con- 
stant feature  of  the  eruption.  The  two  corresponding  sides  of  the  body  are 
usually  invaded  equally  and  by  a  somewhat  similar  form  of  the  eruption.  This 
tendency  to  symmetrical  development  is  not  observable  in  tertiary  eruptions. 

The  polymorphism  of  secondary  syphilides  is  at  times  the  feature  of  most 
importance  in  establishing  a  correct  diagnosis.  This  term  implies  that  the  lesion 
is  many-formed;  that  is,  while  in  one  part  of  the  body  it  is  macular,  in  another 


718  GENITO-URINARY  SURGERY 

it  is  papular,  in  still  another  pustular,  etc.  The  skin  diseases  which  syphilis 
simulates  usually  conform  to  one  type;  that  is,  if  certain  lesions  are  observed 
in  one  part  of  the  body,  similar  lesions,  and  no  others,  will  be  observed  in 
other  parts.    This  is  not  the  case  with  syphilis,  except  at  the  beginning. 

Usually  the  eruption  develops  gradually,  first  in  the  form  of  an  erythema 
so  slight  as  not  to  be  noticed  till  the  patient's  skin  is  exposed  to  the  air,  when 
the  eruption  appears  on  the  anterior  and  lateral  aspects  of  the  chest  and  belly 
as  an  exaggeration  of  that  mottling  which  constantly  occurs  when  a  portion  of 
the  surface  generally  covered  is  suddenly  chilled.  This  erythema  becomes  quite 
distinct  in  a  few  days.  It  persists  and  gradually  shows  the  pigmentary  changes; 
but  in  the  meantime  papules  are  developing  in  certain  regions,  or  perhaps  pus- 
tules or  vesicles.  The  multiform  eruption  is  due  to  the  fact  that  the  lesions 
persist,  one  variety  not  completing  its  course  before  another  is  developed. 
The  general  eruption  receives  its  name  from  the  predominant  lesion. 
The  superficial  character  of  the  early  syphilides  is  due  to  the  tendency  of 
bacterial  growth  to  occur  in  regions  where  the  blood-current  is  slowed.  The 
most  marked  efforts  of  the  disease  in  this  early  secondary  stage  are,  therefore, 
shown  in  the  papillary  layer  of  the  skin,  the  epidermis  becoming  secondarily 
involved. 

The  Influence  of  Mercurial  Treatment. — Although  individual  lesions  may 
persist  for  months  in  spite  of  most  careful  medication,  the  usual  effect  of 
efficient  mercurial  treatment  upon  general  secondary  syphilitic  eruptions  is 
prompt  and  pronounced.  Within  a  week  the  eruption  is  undergoing  rapid 
resolution.  This  gives  a  means  of  diagnosis  which  in  doubtful  cases  is  exceed- 
ingly valuable. 

Eruptions  of  the  Mucous  Membranes. — Involvement  of  the  mucous 
membrane  of  the  mouth  is  one  of  the  most  constant  symptoms  of  constitutional 
syphilis.     It  often  occurs  even  before  the  skin  eruptions. 

It  may  appear  in  the  form  of  an  acute  erythema  (acute  syphilitic  angina), 
involving  the  palate,  half-arches,  tonsils,  and  pharynx,  accompanied  by  a  marked 
cedema,  closely  resembling  the  non-specific  sore  throat,  and  generally  ascribed 
to  catching  cold;  more  commonly  it  appears  in  the  form  of  mucous  patches. 
Indeed,  these  are  the  most  constant  lesions  of  secondary  syphilis.  They  are 
commonly  found  on  the  tongue,  the  buccal  mucous  membrane,  the  half-arches, 
the  tonsils,  and  the  palate.  Exceptionally  they  extend  from  the  posterior  half- 
arch  to  the  pharyngeal  mucous  membrane.  They  appear  as  gray-white,  irregu- 
larly shaped  markings,  not  elevated  above  the  surrounding  healthy  surface. 
The  appearance  presented  by  an  individual  lesion  is  very  like  that  produced  by 
brushing  the  mucous  membrane  with  a  stick  of  silver  nitrate,  except  that  the 
margins  of  the  mucous  patch  are  more  sharply  defined. 

Together  with  the  mucous  patches  there  are  often  erosions  and  fissures 
of  the  tongue.  The  latter  when  deep  and  placed  at  the  sides  of  the  organ  are 
painful,  though  the  mouth  eruption  of  secondary  syphilis  conforms  to  the 
general  character  of  the  disease  in  presenting  few  subjective  symptoms.  Con- 
tact with  irritating  or  very  hot  foods  may,  however,  cause  pain. 

Both  the  mucous  patch  and  acute  erythema  also  rarely  develop  in  the 
urethra  of  the  male,  giving  rise  to  a  discharge  which  may  simulate  a  mild 


SYPHILIS  719 

attack  of  gonorrhoea.  In  the  female  there  may  be  acute  erythema  of  the  vagina; 
more  commonly,  indeed,  in  the  majority  of  cases,  mucous  patches  develop  about 
the  vaginal  outlet. 

Syphilitic  Alopecia. — The  impaired  nutrition  of  the  hair-follicles  incident 
to  constitutional  syphilis  causes  the  hair  to  lose  its  lustre  and  to  come  out  in 
irregular  patches.  Usually  the  scalp  and  the  eye-brows  are  alone  affected. 
Sometimes  all  the  hairy  regions  are  involved,  and  there  results  complete  denuda- 
tion of  the  entire  body. 

The  rapid  onset  of  the  baldness,  the  irregularity  of  distribution,  and  the 
fact  that  under  constitutional  treatment  it  is  usually  completely  curable  are 
characteristic  features  of  the  condition. 

At  times  alopecia  attacks  the  eyebrows  alone,  causing  an  irregular  bald 
patch.  This  is  so  peculiar  to  syphiHs  that  it  is  considered  diagnostic  (Fournier). 

The  alopecia  which  comes  on  later  in  the  disease  as  a  consequence  of  ulcer- 
ative lesions  is  due  to  atrophy  of  the  hair- follicles,  and  is  incurable. 

Syphilitic  onychia  is  dependent  upon  impaired  nutrition  of  the  nail 
matrix,  and  is  commonly  associated  with  the  papular  or  pustular  eruptions. 
The  nails  may  become  brittle  and  lustreless,  or  may  be  hypertrophied  and 
deformed,  or  may  exfoliate.  These  processes  are  associated  at  times  with  deep 
ulceration  around  the  nails  (perionychia). 

Syphilitic  Involvement  of  the  Viscera. — At  about  the  time  the  early 
constitutional  symptoms,  such  as  general  lymphatic  enlargement,  fever,  and 
syphilodermata,  develop,  there  may  be  manifestations  of  the  disturbing  effect 
of  the  virus  upon  the  viscera,  though  such  signs,  at  least  in  their  more  serious 
forms,  do  not  usually  occur  till  late  in  the  disease.  The  visceral  symptoms 
which  develop  in  early  secondary  syphilis  are  nearly  always  dependent  upon 
an  acute  h3T3eraemia  which,  though  caused  by  the  syphilitic  poison,  differs  in 
no  way  from  similar  conditions  brought  about  by  other  causes,  except  in  the 
fact  that  it  yields  promptly  to  specific  treatment.  Thus  there  may  be  tem- 
porary albuminuria  from  hypergemia  or  inflammation  of  the  kidney,  violent 
cephalalgia  from  meningitis,  pleural  effusion  from  pleuritis. 

In  the  early  stage  of  secondary  syphilis  the  liver  may  be  hypertrophied. 
This  may  be  accompanied  either  by  pain  or  by  jaundice,  or  by  both  of  these 
symptoms.  Jaundice  does  not  appear  as  an  isolated  symptom  of  syphiHs. 
Sjrphilides  of  the  skin  or  of  the  mucous  membrane  are  found  associated  with  it. 

It  is  more  convenient  to  consider  under  tertiary  S3^hilis  the  effects  of  the 
disease  on  the  muscles,  the  bones,  the  nervous  and  vascular  systems,  and  the 
viscera,  since  the  secondary  manifestations  of  the  disease  in  these  portions  of  the 
body  are  transitory  and  comparatively  rare,  and  present  only  the  ordinary 
symptoms  of  a  more  or  less  acute  inflammation. 

It  is  noteworthy  that  the  symptoms  in  connection  with  the  viscera  become 
less  acute  in  type  as  the  attack  of  syphiHs  becomes  older,  and  that  when 
they  develop  they  resemble  the  chronic  rather  than  the  acute  form  of  inflam- 
mation, until  finally  in  the  tertiary  period  the  formation  of  gummata  takes  place. 

Syphilitic  Disturbances  of  the  Nervous  System. — ^The  commonest 
symptom  of  involvement  of  the  nervous  system  in  constitutional  syphilis  is  the 
syphilitic  neuralgia  to  which  reference  has  already  been  made.     This  and  the 


720  GENITO-URINARY  SURGERY 

other  symptoms  may  be  dependent  upon  the  general  cachexia,  or  more  rarely 
may  be  due  to  pressure,  as  from  enlarged  lymphatics  or  swelling  of  the  medulla 
■or  the  periosteum  of  bones.  The  first  and  second  branches  of  the  trifacial  nerve 
are  especially  subject  to  this  form  of  syphilitic  neuralgia. 

Cephalalgia  is  common  in  the  early  secondary  period.  It  is  usually  of 
moderate  severity,  is  not  a  surface  pain,  but  is  located  in  the.  frontal  or  the 
occipital  region  of  the  brain,  and  is  harassing  rather  than  disabling;  three 
are  nocturnal  exacerbations.    Very  exceptionally  it  becomes  exceedingly  severe. 

Analgesia  when  present  is  found  over  the  metacarpal  region  of  each  hand. 
It  is  an  early,  usually  symmetrical  lesion,  and  is  not  accompanied  by  anaesthesia, 
tactile  sensation  being  retained.  It  may  exceptionally  take  the  form  of  thermo- 
analgesia  or  muscular  analgesia. 

Paralysis,  particularly  of  the  muscles  of  the  eye  and  the  face,  is  occasionally 
observed  in  early  syphilis.  It  may  involve  single  muscles  or  muscle  groupS;  or 
may  cause  hemiplegia  or  paraplegia. 

The  nerve  manifestations  of  secondary  syphilis  are  usually  short-lived  and 
yield  quickly  to  constitutional  treatment. 

Syphilitic  involvement  of  the  bones,  joints,  and  tendinous  sheaths 
is  not  rare  in  the  secondary  stage  of  the  disease.  The  bones  lying  nearest  the 
surface  exhibit  painful  nodular  swellings  with  the  characteristic  symptoms  of 
acute  periostitis.  One  or  many  joints  may  be  the  seat  of  more  or  less  acute 
inflammation.  Certain  of  the  tendinous  sheaths  may  develop  the  crackling  and 
tenderness  of  tenosynovitis. 

Iritis  is  the  commonest  eye  manifestation  of  secondary  syphilis;  it  may 
assume  the  plastic  or  the  serous  form.  In  either  case  the  symptoms  are  like 
those  of  the  inflammatory  form  of  the  disease,  except  that  they  are  less  acute. 

Epididymitis  occasionally  develops -as  a  lesion  of  early  constitutional  dis- 
ease; it  is  unilateral,  painless,  and  quickly  subsides  on  treatment.  Orchitis  is 
rarely  observed  till  the  tertiary  stage. 

As  a  result  of  secondary  syphilis,  menstrual  disturbances  are  very  common: 
these  may  take  any  of  the  forms  noted  in  debility  from  other  causes.  Both 
amenorrhoea  and  metrorrhagia  have  been  observed.  In  the  pregnant  uterus 
abortion  generally  occurs. 

SYPHILITIC  SKIN  ERUPTIONS 

It  should  be  remembered  that  recent  syphilides  (secondary)  are  superficial, 
while  later  eruptions  (tertiary)  are  deep,  but  that  typical  tertiary  eruptions 
may  exceptionally  appear  in  the  secondary  stage  of  the  disease,  or  the  second- 
ary eruptions  may  appear  late.    The  skin  lesions  of  syphilis  may  be  classed  as 

follows:     • 

1.  Erythematous  syphilides,  called  also  erythema,  macules,  roseola. 

2.  Papular  syphilides.  In  accordance  with  their  size,  shape,  and  surface, 
the  papular  syphilides  are: 

A.  Conical   or   acuminated  papular  syphilides. 

a.  Large. 

b.  Small. 


SYPHILIS  721 

B.  Flat  or  lenticular  papular  syphilides. 

a.  Large. 

b.  Small. 

C.  Moist  papules  (mucous  patches). 

D.  Papulo-squamous  syphilides. 

3.  Vesicular  syphilides. 

4.  Pustular  syphilides. 

a.  Small,   acuminated  pustular  syphilides    (miliary). 

b.  Large,  acuminated  pustular  syphilides   (acneiform). 

c.  Small,  fiat  pustular  syphilides  (impetiginous). 

d.  Large,  flat  pustular  syphiHdes  (ecthymatous). 

5.  Pigmentary  syphilides. 

6.  Bullous  syphilides. 

7.  Tubercular  syphilides. 

8.  Gummatous  syphilides. 

A  pathological  study  of  the  secondary  skin  eruptions  shows  that  they  are 
made  up  of  a  small  round-celled  infiltration  of  the  cutis  and  adnexa,  together 
with  the  lower  layers  of  the  rete  Malpighii.  The  blood-vessels  are  dilated,  the 
endothelium  is  thickened,  and  there  is  a  small-celled  infiltrate  of  the  adventitia. 
These  changes  involve  the  vessels  of  the  papillae,  the  Malpighian  network,  the 
hair-follicles,  the  sebaceous  glands,  and  the  sweat-glands.  Whether  the  eruption 
be  macular,  papular,  or  pustular,  the  pathology  is  the  same. 

The  pathology  of  the  tertiary  lesions  differs  from  that  of  the  secondary  only 
in  that  the  small-celled  infiltrate  is  much  more  extensive,  invading  the  entire 
thickness  of  the  skin  and  the  subcutaneous  tissues.  As  a  result,  this  mass  of 
embryonal  tissue,  always  poorly  vascularized,  degenerates  centrally,  and  either 
ulcerates,  discharging  externally,  or  is  partly  absorbed  and  partly  converted  into 
fibrous  tissue. 

Grouping  the  skin  lesions  in  accordance  with  the  time  of  development,  the 
eruptions  of  the  secondary  period  are: 

The  erythematous  syphilides  (roseola) ;  the  papular  and  papulo-squamous 
syphilides  (mucous  patch,  lichen,  condyloma,  psoriasis,  etc.);  the  general 
pustular  syphilides  (acne,  impetigo) ;  the  pigmentary  syphilides;  the  bullous 
syphilides;  the  vesicular  sjqshilides;  the  tubercular  syphilides. 

During  the  same  time  there  may  develop  on  the  mucous  membranes: 

1.  An  acute  erythema; 

2.  Mucous  and  scaly  patches;  or, 

3.  Superficial  ulcerations. 

With  the  exception  of  the  pigmentary  syphilide  and  the  squamous  form  of 
the  papular  syphilide,  these  are  general  eruptions  and  appear  during  secondary 
syphilis  in  about  the  order  given,  the  tubercular  lesion  being  well  on  the  border- 
line between  the  secondary  and  the  tertiary  period. 

The  syphilides  of  the  tertiary  stage  are  pustular  and  bullous  syphilides,  which 
appear  discretely  or  in  groups,  and  which  ulcerate  deeply  (ecthyma,  rupia), 
and  gummata. 

The  mucous  membrane  manifestations  of  this  stage  are  mucous  and  scaly 
patches  and  gummata. 
46 


722 


GENITO-URINARY  SURGERY 


Eeythi;3lLATous  Syphilide. — This  is  the  earliest  and  the  most  constant  of 
all  the  skin  lesions  of  s}-philis.  It  appears  about  the  same  time  that  the  general 
h-mphatic  enlargements  become  apparent.     In  the  uncleanly  and  careless  it 


•I 


■^■s 


J 


Fig.  376. — Erytnematoiis  syphilide. 


(From  the  collection  of  photographs  of  Dr.  George  Henry 
Fox.) 


may  run  its  course  without  attracting  the  attention  of  the  patient.  The 
eruption  exhibits  less  of  the  rounded  shape  or  grouping  than  any  of  the  other 
syphilides. 


SYPHILIS 


723 


It  first  appears  as  an  irregular  rose-red  mottling  of  the  surface,  such  as  is 
constantly  seen  when  covered  surfaces  are  exposed  to  the  cold.  The  lesion  may 
not  develop  beyond  this  point,  terminating  promptly  under  treatment,  or  at 
times  even  without  it,  in  a  slight  branny  epithelial  shedding.     More  commonly 


Fig.  377. — Flat  papular  syphilide. 

syphilitic  roseola  develops — that  is,  patches  of  varying  size  are  formed,  the 
smallest  not  larger  than  a  pin-head,  the  largest  the  size  of  a  quarter-  or  a  half- 
dollar  (Fig.  376).  These  patches  are  irregular  in  shape,  frequently  rounded 
or  oval,  but  not  necessarily  so  and  shortly  become  raw-ham  or  even  coppery 
in  color.    At  first  pressure  of  the  finger  and  emptying  of  the  superficial  vessels 


724 


GZXITO-URIXARY  SURGERY 


Fig.  378. — Acuminated  papular  syphilide.     (From  the  collection  of  photographs  of  Dr.  George  Henry 

Fox.) 


SYPHILIS 


725 


Fig.  3  79. — Acuminated  papular  syphilide.    (From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


726 


GENITO-URINARY  SURGERY 


leave  the  skin  white  in  the  first  days  of  the  eruption,  but  later  there  is  distinct 
pigmentation,  the  copper  color  remaining. 

The  eruption  commonly  appears  on  the  sides  and  front  of  the  belly  and  chest. 
It  is  also  frequently  observed  on  the  back  and  on  the  flexor  surfaces  of  the 
extremities.  It  is  sometimes  seen  at  the  hair-line  of  the  forehead  and  upon 
the  palmar  and  plantar  surfaces.  It  may,  of  course,  develop  on  any  surface 
of  the  body,  but  the  regions  just  given  are,  in  their  order,,  those  of  preference. 

The  full  erythematous  eruption  develops  in  about  a  week.    Under  treatment 


Fig.  380. — Large  flat  papular  syphilide.     (From  the  collec- 
tion of  photographs  of  Dr.  George  Henry  Fox.) 

it  rapidly  disappears,  even  the  pigment  being  absorbed  and  leaving  no  trace. 
If  not  treated,  it  lasts  for  weeks  or  months,  and  is  accompanied  by  papular 
and  pustular  lesions,  giving  the  eruption  one  of  its  characteristic  features — 
polymorphism. 

Diagnosis. — The  diagnosis  of  the  erythematous  syphilide  is  much  simplified 
by  the  presence  of  concomitant  signs  of  the  disease.  At  this  stage  the  remains 
of  a  chancre  are  usually  present,  the  enlarged  lymph-nodes  can  be  felt,  and 
a  history  of  rheumatoid  pains,  of  sore  throat,  of  headache,  and  of  a  slight 
feverish  attack  will  be  given. 


SYPHILIS 


727 


Simple  er>'thema  and  the  copaiba  rash  may  both  simulate  syphilitic  roseola. 
Simple  erythema,  however,  is  not  associated  with  a  history  of  chancre  or  with 
the  signs  of  early  secondary  syphilis,  is  more  commonly  accompanied  by  dis- 
tinct fever  and  digestive  disorder,  itches,  and  develops  and  subsides  in  a  short 
time,  showing  no  tendency  to  persist  and  to  become  pigmented. 

The  copaiba  rash  often  exhibits  large  itching  confluent  patches  which  run 
their  course  in  a  few  days,  which  appear  with  special  intensity  in  certain  regions, 
such  as  the  extensor  surfaces  of  the  joints,  and  which  subside  promptly  on  stop- 


FiG.  381. — Large  flat  papular  syphilide.     (From  the  collec- 
tion of  photographs  of  Dr.  George  Henry  Fox.; 

ping  the  drug.  There  is  a  history  of  ingestion  of  copaiba,  or,  if  this  is  denied, 
an  examination  of  the  urine  will  demonstrate  the  copaiba  odor. 

Measles  is  characterized  by  a  history  of  exposure  to  the  disease,  KopHk's 
spots,  high  fever,  cough,  an  eruption  beginning  on  the  face  and  becoming  uni- 
versal rapidly,  and  the  pinkish-red,  blotchy  appearance  of  the  macules. 

Papular  Syphilide. — The  lesions  of  the  papular  s^philoderms  appear  as 
hard,  small  or  large,  acuminated  or  flat,  smooth  or  scaling,  rounded  elevations, 
exhibiting  a  characteristic  raw-ham  or  copper  color.    These  lesions  are  due  to 


728 


GENITO-URINARY  SURGERY 


Jt^      ^-Sii     'ju'  ^t. 


circumscribed  hyperaemia,  together  with  cellular  infiltration  of  the  papillary  layer 
of  the  skin.    They  are  frequently  converted  into  vesicles  or  pustules. 

The  Small  Papular  Syphilide. — This  eruption  is  usually  an  early  manifes- 
tation of  constitutional  syphilis,  exceptionally  even  preceding  the  roseola;  fre- 
quently it  does  not  develop  till  considerably  after  the  fourth  month.  The 
papules  may  be  conical,  rounded,  flat  (lenticular),  or  umbilicated,  and  often 
exhibit  a  fine  scaling.  They  vary  in,,  size  from  that  of  a  pin-head  to  that 
of  a  split  pea.  At  first  rose-red,  they  become  raw-ham  or  coppery  in  color. 
The  lesions  are  apt  to  exhibit  a  circinate  grouping,  appearing  as  segments  of 
circles,  as  complete  circles,  or  in  figures  of  eight.    The  eruption  is  usually  well 

ma-rked  and  involves   a  large  surface 
(Fig.  377). 

The  acuminated  (miliary)  form  is 
first  noticed  on  the  face.  It  subse- 
quently appears  on  the  trunk  and  the 
extremities. 

The  flat,  lenticular,  lichen-like  form 
appears  first  about  the  shoulders,  but 
the  face,  body,  and  extremities  are  soon 
involved,  the  lesions  being  particu- 
larly abundant  about  the  flexures  of 
the  joints.  The  palmar  and  plantar 
surfaces  also  suffer.  The  eruption  is 
somewhat  chronic  in  its  course,  and  is 
more  resistant  to  treatment  than  the 
erythema.    It  is  subject  to  relapses. 

The  Large  Papular  Syphilide. — 
As  in  the  smaller  lesions,  these  papules 
may  be  conical  or  flat. 

The  large  conical  papules  are  usually 
discrete,  few  in  number,  are  found 
associated  with  the  small  papules,  and 
are  most  abundant  on  the  back,  the 
buttocks,  the  back  of  the  neck,  the  face, 
and  the  extensor  surface  of  the  thighs 
(Figs.  378  and  379). 
The  large,  flat  papules  vary  in  size  from  that  of  a  shirt-button  to  that 
of  a  penny  (Figs.  380,  381,  and  382).  They  are  sharply  circumscribed,  ele- 
vated, and  commonly  exhibit  a  branny  scaling.  The  eruption  may  be  widely 
distributed  or  may  be  grouped  in  certain  regions.  Thus,  the  lesions  are  fre- 
quently found  on  the  back,  the  nape  of  the  neck,  the  forehead,  the  flexor 
surfaces  of  the  extremities,  and  the  scrotum,  and  about  the  mucous  outlets 
(Fig.  383).  Sometimes  the  lesions  become  fissured,  and  may  give  rise  to 
severe  pain.  This  is  especially  apt  to  occur  on  the  hands  and  feet  and  about 
the  mouth  and  the  anus. 

Mucous  Patch. — When  the  papular  syphilide  develops  on  surfaces  of  the 
body  which  are  kept  constantly  moist  by  secretions,  or  which  are  subject  to 


Fig.  3S2. — Large  flat  'papular  syphilide. 


SYPHILIS 


729 


moisture  and  friction,  as  on  mucous  surfaces  at  the  angles  of  the  mouth  (Fig. 
384),  beneath  the  dependent  mammary  gland,  about  the  anus  (Fig.  385), 
and  the  vulva  (Fig.  386),  within  the  foreskin,  on  the  scrotum,  or  between 


Fig.  383. — Large  flat  papular  syphilide,  showing  scaling. 

the  toes,  instead  of  the  branny  scaling  which  characterizes  the  dry  lesion  there 
is  often  abraded  surface,  which  secretes  freely  and  is  partly  or  completely 
covered  by  a  gray,  adherent,  offensive  pseudo-membrane.    The  irritating  secre- 


730 


GEXITO-URINARY  SURGERY 


Pig.  384. — Mucous  patches  of  the  lips.  FiG.  385. — Mucous  patches  about  the  anus. 


Fig.  386. — Vegetations  and  mucous  patches  about  the  vulva. 


SYPHILIS 


731 


tions  of  these  mucous  patches  frequently  give  rise  to  warty  growths  in  the 
immediate  environment.  Sometimes  the  moist  papule  exhibits,  in  addition  to 
hypersemia,  cell  infiltration  and  abrasion,  or  superficial  ulceration,  a  distinct 
papillary  overgrowth,  forming  small  or  large  papillomata  (Fig.  387).  These 
are  properly  termed  condylomata,  and  should  be  distinguished  from  the  mucous 
patch  in  which  hypertrophy  of  the  papillae  either  is  not  present  or  is  not 
marked.  Commonly  these  condylomata  appear  as  raised  flat,  raw  surfaces,  the 
cellular  infiltration  being  so  abundant  that  the  papillary  nature  of  the  growth 
is  but  imperfectly  marked.    Occasionally  large  cauliflower-like  warty  growths 


Fig.  387. — Papular  syphilide,  showing  papillary  overgrowth. 


are  formed,  particularly  in  the  regions  of  the  face,  scalp,  shoulders,  and  geni- 
tals (Duhring).  These  are  termed  vegetating  papules,  and  are  often  accom- 
panied by  abrasions  and  crusting  of  the  surrounding  skin  (Fig.  388). 

^Vhen  subject  to  friction  and  not  treated,  the  mucous  patches  may  form 
ulcers.  On  the  delicate  skin  of  babies  mucous  patches  frequently  develop 
and  are  in  them  one  of  the  commonest  lesions  of  syphilis.  In  the  adult  they 
appear  early,  are  prone  to  relapses,  and  may  occur  in  the  mouth  even  during 
the  tertiary  stage  of  syphilis.  The  secretions  of  the  mucous  patch  are  highly 
contagious. 

Diagnosis  of  the  Papular  Syphilides. — The  concomitant  signs  of  S3rphilis, 


732 


GENITO-URINARY  SURGERY 


such  as  the  remains  of  a  chancre,  enlarged  lymphatic  nodes,  sore  throat, 
alopecia,  scabs  in  the  hair,  etc.,  are  usually  present,  and,  in  conjunction  with 
the  copper  color  of  the  eruption,  its  polymorphism,  the  absence  of  itching, 
and  its  grouping  about  the  back,  the  neck,  the  forehead,  the  sides,  and  the 
buttocks,  render  the  diagnosis  of  this  syphilide  easy. 

When  the  large,  flat,  papular  syphilides  develop,  either  in  the  dry  form 
or  as  mucous  patches,  the  diagnosis  can  be  made  with  certainty,  since  these 
lesions  are  absolutely  characteristic  of  syphilis  and  are  simulated  by  no  skin 
disease. 

Acne  papulosum  and  lichen  are  both  closely  simulated  by  some  forms  of 
the  papular  syphilides. 


Fig.  388. — Syphilitic  vegetations. 

Acne  papulosum  is  associated  with  none  of  the  concomitant  signs  of  syphilis, 
is  found  commonly  about  the  forehead,  cheeks,  chin,  shoulders,  and  back,  leaves 
no  pigmentation  at  the  seat  of  cured  lesions,  and  is  often  accompanied  by 
pustules;  or  there  may  be  scars  resulting  from  the  healing  of  the  latter.  When 
papular  acne  develops  only  on  the  forehead,  the  diagnosis  must  be  formed 
mainly  on  the  absence  of  other  signs  of  syphilis. 

Lichen  may  be  acum.inate  or  flat,  and  may  be  widely  distributed.  The 
lesions  of  this  disease  are  dusky  in  color  and  occasion  pigmentation  of  the 
skin.  The  individual  papules  are,  however,  angular  in  outline  rather  than 
rounded,  and  in  place  of  a  circular  grouping  are  often  arranged  in  rows  or 


SYPHILIS 


7ZZ 


Fig.   389. — Papulo-squamous  syphilide.      (From   the   collec- 
tion  of   photographs   of    Dr.    George    Henry   Fox.) 


734  GENITO-URINARY  SURGERY 

lines.  They  usually  itch,  and  are  not  associated  with  any  of  the  signs  of 
syphilis.     The  eruption,  however  diffuse  it  may  be,  is  papular  throughout. 

Keratosis  pilaris,  the  conical  elevations  seated  about  the  apertures  of  the 
nair-follicles  and  mostly  found  on  the  extensor  surfaces  of  the  thighs  and 
arms  and  on  the  forearms,  is  sometimes  mistaken  for  the  small  miliary  syphilide. 
The  absence  of  circular  grouping,  the  distribution  of  the  lesion,  the  uniform 
appearance  presented  by  it,  and  the  fact  that  each  papule  is  invariably  placed 
at  the  aperture  of  a  hair  follicle,  will,  in  the  absence  of  other  signs  of  syphilis, 
render  diagr:r,sis  piisy. 

Prognosis. — Papular  syphilides  yield  to  treatment,  leaving  a  brownish 
pigmentatiorj,  which  ultimately  disappears.  The  effect  of  mercury  is  not  so 
immediate  as  in  the  case  of  roseola.  Still,  in  a  few  weeks  a  general  papular  erup- 
tion usually  fades  completely  under  constitutional  treatment.  The  recurrent  forms 
are  somewhat  more  obstinate.    These  are  prone  to  appear  in  circinate  groups. 


Fig.  390. — Gummata  of  cheek  and  nose. 

Papular-Squamous  Syphilides. — There  is  more  or  less  desquamation  with 
all  the  papular  syphilides,  but  in  some  cases  this  may  be  so  marked  as  to  give 
the  disease  a  distinctly  squamous  type.  The  lesions  in  this  form  of  syphiloderm 
are  generally  flat,  and  are  covered  with  fine  gray  scales,  which  are  not  very 
tightly  adherent.  As  these  scales  are  brushed  away,  the  coppery,  glistening 
surface  of  the  papule  is  exposed,  surrounded  with  a  fairly  well-marked  collar 
of  ragged  epithelium. 

These  lesions  when  they  appear  early  may  be  multiple  and  general,  the 
patches  varying  in  size  as  do  those  of  papular  syphilis  (Fig.  389  and  Plate  XV). 
They  may  remain  weeks  or  months  without  increasing  in  size,  and  commonly 
exhibit  a  distinct  circinate  arrangement  of  the  individual  papules  of  a  group. 

The  well-marked  papulo-squamous  syphilides  usually  appear  after  the  sixth 
month,  and  may  develop  in  any  subsequent  period  of  the  disease.  The  dis- 
tribution of  this  lesion  is  similar  to  that  of  the  papular  syphilide. 

On  the  palms  and  soles  these  papulo-squamous  eruptions  are  most 
frequent  and  most  resistant  (Fig.  392  and  Plate  XVI).  In  the  early  period 
of    the    disease    they    are    symmetrical;    later    this    feature    is    not    noted. 


PLATE  XV. 


gourtesy,  Dr.  M.  B.  Hart/ell 

Papulo-squamous  syphilide. 


PLATE  XVI. 


Courtesy,  Pr.  JI.  B.  Hait/.ell 

Papulo-squamous  syphilide  of  the  hand. 


SYPHILIS 


735 


Instead  of  the  familiar  macule  with  gUstening  coppery  centre  and  gray  epi- 
thelial scales  about  the  edges,  there  may  be  a  marked  overgrowth  of  the  corne- 
ous layer  of  the  skin,  forming  hard  conical  projections  in  size  from  that  of  a 
pin-head  to  that  of  a  pea.  These  can  be  dug  out  from  the  skin,  leaving  deep 
pits  or  depressions.     They  are  most  frequently  noted  on  the  soles,  and  are 


Fig.   391. — Papulo-squamous  syphilide. 


(From   the   collection   of   photographs   of    Dr.    George 
Henry  Fox.) 


liable  to  occasion  pain  on  walking.     The  papulo-squamous  syphilides  of  the 
palms  and  soles  are  often  complicated  by  painful  and  obstinate  fissures. 

These  lesions  may  appear  in  the  third  month,  or  much  later.  They  are 
prone  to  relapse,  beginning  about  the  centre  of  the  palm  and  extending  pe- 
ripherally, forming  lesions  of  circinate  or  serpiginous  shape. 


Fig.  392.- 


-Papulo-squamous  syphilide  of  the  hand.       CFrom  the  collection  of  photographs  of  Dr. 
George  Henry  Fox.) 


Papulo-squamous  eruption  of  the  pg-lms  or  soles  alone,  accompanied  by 
but  slight  subjective  symptoms,  is  almost  pathognomonic  of  syphilis.  Excep- 
tionally the  palmar  syphilide  appears  as  a  diffuse  exfoliation  of  fine  epithelial 
scales,  giving  the  surface  a  silvery  aspect. 

Diagnosis. — Papulo-squamous  syphilides  must  be  distinguished  from  psori- 
asis and  from  palmar  eczema. 


'j'i^(^  GENITO-URINARY  SURGERY 

Psoriasis  is  entirely  superficial,  exhibiting  but  slight  thickening,  is  not 
polymorphous,  frequently  appears  before  the  twentieth  year,  its  individual 
lesions  are  not  markedly  raised  above  the  level  of  the  surrounding  surface, 
it  is  covered  with  a  thick,  imbricated  skin,  made  up  of  white  scales,  is  generally 
symmetrical  (the  late  syphilitic  papulo-squamous  eruption  does  not  usually  ex- 
hibit this  feature),  is  rarely  confined  to  the  palms  and  the  soles,  being  com- 
monly associated  with  similar  lesions  grouped  about  the  extensor  surfaces 
of  the  knees  and  the  elbows,  is  always  dry,  is  extremely  chronic,  is  subject 
to  relapses  and  obstinate  to  treatment,  is  not  influenced  by  mercury,  and  pri- 
marily is  not  associated  with  other  signs  or  symptoms  of  syphilis. 

Eczema  of  the  palms  is  attended  vidth  discharge,  crusting,  and  itching; 
it  begins  about  the  wrist  first,  and  not  in  the  centre  of  the  palm,  and  is  not 
as  sharply  outlined. as  the  specific  lesion.  When  palmar  or  plantar  syphilides 
become  fissured  or  eroded  they  cannot  be  distinguished  from  eczema.  Their 
reaction  to  specific  treatment  is  so  slow  that  the  therapeutic  test  is  of  little 
service. 

The  circinate  form  of  papulo-squamous  syphiloderm  may  closely  resemble 
the  lesion  of  tinea  circinata;  the  latter  is,  however,  progressive,  and  micro- 
scopic examination  shows  the  parasite. 

Prognosis. — The  lesions  are  obstinate,  but  ultimately  heal;  they  may 
leave  permanent  scarring.     Their  pigmentation  disappears. 

Vesicular  Syphilide. — This  eruption  is  exceedingly  rare.  It  may  closely 
simulate,  so  far  as  the  skin  lesions  are  concerned,  almost  any  of  the  non- 
specific vesicular  diseases.  Thus  there  are  the  eczematous  form,  the  varicel- 
loid form,  and  the  herpetic  form. 

The  vesicles  may  be  small  or  large,  may  be  generalized,  or  may  come  out 
in  groups  in  certain  regions  of  the  body.  They  are  prone  to  appear  about 
the  hair-follicles.  The}^  are  observed  on  the  face,  the  trunk,  and  the  ex- 
tremities. If  there  are  seats  of  preference,  these  are  perhaps  the  face,  genitalia, 
forearms,  and  legs. 

The  eczematous  form  appears  as  a  general  eruption  of  small  vesicles,  either 
discrete  or  in  patches,  and  generalh^  sparing  the  face.  When  the  vesicles  are 
discrete,  each  is  surrounded  by  a  characteristic  raw-ham-colored  areola.  If 
the  fluid  of  the  vesicles  remains  clear,  it  may  break  through  its  thin  epider- 
mic wall  and  escape,  or  may  be  reabsorbed,  leaving  only  a  slight  epidermic 
exfoliation  and  temporary  pigmentation;  frequently,  however,  pustulation  takes 
place,  and  thin  3'ellow  crusts  are  formed  (impetigo).  This  last  form  is  prone 
to  appear  on  the  face  and  about  the  genitalia,  and  is  usually  associated  with 
papular  and  pustular  lesions  on  other  parts  of  the  body. 

The  diagnosis  from  vesicular  eczema  will  be  made  by  the  characteristic 
areola,  the  absence  of  itching  and  of  acute  inflammatory  signs,  the  influence 
of  mercury,  and  the  presence  of  associated  signs  of  syphilis. 

The  varicelloid  form  appears  as  large,  not  very  numerous,  discrete,  split- 
pea-sized  vesicles,  either  globular  or  umbilicated,  which  persist  for  some  time, 
and  then  rupture,  leaving  an  area  of  slight  crusting  and  pigmentation.  Or 
they  may  pustulate  (presenting  the  appearance  of  varioloid)  and  crust.  The 
base  of  each  vesicle  is  surrounded  by  a  characteristic  copper-colored  areola, 


SYPHILIS  IV 

and  other  syphilides  are  usually  present.  Were  the  patient  suffering  from  a 
well-marked  fever,  the  syphilitic  eruption  might  readily  be  taken  for  either 
varicella  or  varioloid,  according  to  its  type.  A  history  of  the  case,  and  the 
concomitant  signs  of  constitutional  syphilis,  should  quickly  establish  the  proper 
diagnosis. 

The  herpetic  form  of  the  vesicular  syphilide  exhibits  clusters  of  vesicles  of 
various  sizes,  either  irregularly  grouped  or  having  a  distinct  circinate  arrange- 
ment. 

The  lesions  of  the  circinate  form  are  small,  are  not  persistent,  dry  up 
without  rupture,  and  leave  an  area  of  superficial  exfoliation  and  raw-ham- 
colored  staining. 

The  diagnosis  from  ordinary  herpes  is  generally  made  without  trouble. 
Yet  at  times  the  syphilitic  nature  of  the  eruption  can  be  determined  only 
by  the  associated  signs  of  syphilis.  Although  syphilitic  vesicles  as  such  do 
not  persist  for  any  great  length  of  time,  the  copper-colored  macules  or  pustules 
left  after  the  absorption  or  rupture  of  the  vesicles  are  liable  to  remain  for 
many  months. 

Treatment. — The  systemic  treatment  should  be  supplemented  by  mer- 
curial baths  to  prevent  the  vesicles  from  becoming  converted  into  pustules. 

Pustular  Syphilide. — The  syphilitic  pustule  may  be  small  or  large,  and 
either  of  these  varieties  may  be  acuminate  or  flat. 

The  lesions  are  commonly  placed  on  indurated  copper-colored  bases;  they 
may  be  surrounded  by  an  extensive  dusky  areola. 

In  the  early  eruptions,  and  when  the  lesion  first  appears,  the  pus  is  contained 
between  the  raised  epiderm  and  the  true  skin;  later,  deeper  ulcers  may  be 
formed. 

These  syphilides  very  closely  simulate  any  of  the  pustular  nonspecific  skin 
eruptions.  They  are  prone  to  crust,  the  crusts  varying  from  a  dark-yellow  to 
a  dark-green  or  brown-black  color,  and  exhibiting,  when  raised  from  the  sur- 
face of  the  lesion,  a  distinct  punched-out  ulcer  covered  with  viscid  pus. 

When  the  pustular  lesions  heal,  they  leave  marked  pigmentation,  and, 
unless  the  ulceration  is  purely  superficial,  permanent  cicatrices. 

Pustules  commonly  appear  late  in  the  disease;  their  early  development  is 
usually  associated  with  a  severe  form  of  syphilis. 

The  pustular  syphilides  may  develop  on  any  skin  surface;  if  the  lesions 
are  few  in  number  they  are  perhaps  more  frequently  noted  on  the  face,  the 
scalp,  and  the  legs. 

Any  of  the  syphilides  may  be  found  associated  with  pustular  lesions,  and 
even  when  the  predominant  eruption  is  papular  the  pustule  may  be  found  at 
the  same  time  in  all  its  forms  and  at  all  stages  of  evolution.  An  early  pustular 
eruption  is  especially  liable  to  be  preceded  by  syphilitic  fever  of  an  inter- 
mittent type,  with  its  associated  symptoms  of  malaise,  pallor,  inability  to  con- 
centrate the  thoughts,  headache,  insomnia,  articular  pains,  and  sternal  ten- 
derness. 

The  pustular  syphilides  are  somewhat  obstinate  to  treatment,  are  prone 
to  recur,  and  are  more  frequently  followed  by  tertiary  manifestations  than 
when  the  eruption  appears  in  a  macular  or  a  papular  form  (Bassereau).  When 
47 


738 


GENITO-URINARY  SURGERY 


.jj^raSR; 


Fig.  393. — Large  pustular  syphilide.     (From  the  collection  of  photographs  of  Dr.  George  Henry- 
Fox.) 


SYPHILIS  739 

pustulation  has  been  unusually  well  marked  during  the  secondary  stages  of 
the  disease  the  tubercular  and  gummatous  lesions  of  the  tertiary  stage  of  the 
disease  exhibit  a  marked  tendency  to  suppurate. 

Small  Acuminate  Pustular  Syphilide. — This  eruption  is  the  most  super^ 
ficial,  and  usually  in  its  time  of  appearance  the  earliest,  eruption  of  this  group. 
It  is  made  up  of  minute  miliary  pustules,  each  situated  about  a  hair-follicle 
or  the  opening  of  a  sebaceous  gland.  It  is  followed  by  the  formation  of 
small  yellowish  crusts,  leaving  a  pigmented  spot  surrounded  by  a  fringe  of 
exfoliating  epithelium.  On  its  first  appearance  the  eruption  usually  covers  a 
large  surface,  may  be  discrete  or  confluent,  and  exhibits  circinate  grouping. 
Relapses  of  this  syphilide  are  not  apt  to  appear  as  a  general  eruption,  but 
rather  the  lesions  will  be  grouped  in  certain  localities. 

When  the  lesions  become  confluent,  superficial  scabs  are  formed  very  like 
those  observed  in  impetigo.  The  eruption  about  the  lips  is  sometimes  accom.- 
panied  by  a  warty  growth.  This  eruption  corresponds  closely  to  the  small 
vesicular  syphilide,  the  only  difference  being  that  the  raised  epidermis  has  be- 
neath it  pus  instead  of  serum. 

This  pustular  syphilide  does  not  last  long.  Slight  crusting  takes  place, 
and  a  pigmented  spot  is  left  which  is  slow  to  disappear.  Sometimes,  and  this 
is  particularly  true  of  the  relapses,  ulceration  takes  place  and  a  permanent 
cicatrix  is  left. 

Diagnosis. — The  diagnosis  is  founded  upon  the  pigmentation,  and  is  usually 
rendered  easy  by  the  fact  that  this  eruption  very  rarely  appears  alone,  being 
commonly  associated  with  papules  and  roseola. 

Large  Acuminate  Pustular  Syphilide  (Fig.  393). — This  eruption  may 
develop  suddenly,  or  may  form  slowly  with  fever.  When  the  pustules  are 
moderate  in  size,  they  so  closely  resemble  ordinary  acne  that  the  term  syphilitic 
acne  is  very  generally  employed  to  designate  them.  The  individual  lesion  be- 
gins as  a  macule,  which  quickly  becomes  converted  into  a  papule,  then  a 
pustule,  commonly  placed  about  a  hair-follicle,  upon  a  papular,  infiltrated, 
copper-colored  base.  The  pustule  remains  for  one  or  two  weeks  before  rup- 
turing. Then  crusts  are  formed,  which  in  dropping  off  expose  either  a  super- 
ficial ulcer  or,  more  commonly,  a  coppery  papule.  This  and  the  pigmentation 
very  slowly  disappear;   usually  there  is  scarring. 

Syphilitic  acne  may  appear  as  a  general  eruption;  more  commonl\'  it  in- 
vades the  scalp,  face,  and  trunk;  it  is  often  found  on  the  limbs. 

Diagnosis. — ^The  diagnosis  of  the  large  acuminate  pustular  syphilide  will 
be  founded  mainly  on  the  presence  of  other  signs  of  syphilis,  particularly  the 
other  syphilides.  Ordinar\'^  acne  commonly  appears  on  the  face,  chest,  and 
back,  about  the  age  of  puberty,  being  rare  in  late  life,  and  on  the  removal 
of  the  crusts  does  not  exhibit  the  coppery,  lenticular  papule  of  s\'philis.  An 
acne-like  eruption  confined  to  the  trunk  and  the  legs  strongly  suggests  sj'philis. 

Variola  is  a  uniform  eruption,  the  lesions  all  corresponding  to  the  papular, 
then  to  the  pustular  type.  It  is  acute,  follows  definite,  well-marked  prodromes, 
runs  its  course  in  a  few  days,  and  is  attended  with  very  pronounced  constitu- 
tional symptoms.  The  dorsal  surfaces  of  the  wrists  and  hands  and  the  palms 
and  soles  are  nearly  always  affected  with  papules,  followed  by  pustules,  and 


740 


GENITO-URINARY  SURGERY 


/ 


this  disease  occurs  only  in  those  not  protected  by  vaccination.  There  is  little 
danger  of  mistaking  this  eruption  for  a  pustular  syphiloderm.  An  error  the 
reverse  of  this  has  been  made  many  times,  syphilitic  patients  having  been  sent 
to  small-pox  hospitals.  A  diagnosis  can  be  made  at  times  only  after  one  or 
two  days'  observation. 

Small,  Flat  Pustular  Syphilide. — The  lesions  of  this  form  of  syphilide 
closely  resemble  those  of  impetigo.  They  are  more  common  than  the  acumi- 
nate syphilides.  Small,  fiat,  split-pea- 
sized  pustules  form  on  somewhat  ele- 
vated copper-colored  bases.  These  pus- 
tules shortly  rupture,  and  are  followed 
by  rather  thick,  adherent,  yellowish  or 
greenish  crusts.  These  lesions  may  be 
discrete,  may  exhibit  a  circinate  group- 
ing, or  may  be  confluent,  forming  irregu- 
larly shaped  crusts  (pustulo-crustace- 
ous)  Plate  XVII).  In  the  later  periods 
of  the  disease  this  eruption  commonly 
appears  in  the  form  of  irregular  patches, 
often  presenting  a  narrow  crusted  cir- 
cinate border,  which,  spreading  periph- 
erally, encloses  an  area  of  pigmented, 
scarred,  or  normal  skin  (Fig.  394). 

Beneath  the  crusts  of  syphilitic  im- 
petigo are  found  ulcers.  These  may  be 
superficial  or  deep,  the  latter  variety  ap- 
pearing late  in  the  disease.  These  ulcers 
on  healing  leave  depressed,  pigmented 
cicatrices,  which  are  prone  to  scale  for 
months.  The  pigmentation  finally  fades, 
the  scar  remaining  white. 

When  syphilitic  impetigo  appears  as 
an  early  general  eruption,  it  may  last 
but  a  few  weeks.  The  late  confluent 
circinate  and  serpiginous  forms  are  ex- 
tremely chronic. 

The  favorite  seat  is  the  face,  espe- 
cially in  the  hairy  portions,  as  the  beard 
and  the  eyebrows,  and  about  the  nostrils  and  lips  (Figs.  395  and  396).    They 
also  develop  frequently  on  the  scalp  (Fig.  397),  the  chest,  and  the  outer  sur- 
faces of  the  arms  and  legs  (Fig.  398). 

Diagnosis. — The  diagnosis  of  small,  flat  pustular  syphiloderm  is  some- 
times not  possible  from  the  inspection  of  the  lesions  alone,  the  latter  corre- 
sponding very  closely  to  those  of  pustular  eczema  and  impetigo. 

The  crusts  of  pustular  eczema  on  being  raised  show  an  excoriation,  and 
the  disease  is  distinctly  more  inflammatory  in  type  than  the  syphiloderm.    The 


.^' 


Fig.  394. — Pustular  syphilide  (pustulo- 
crustaceous) .  (Prom  the  collection  of  photo- 
graphs of   Dr.   George   Henry  Fox.) 


SYPHILIS 


741 


pustule  of  impetigo  is  discrete,  not  placed  on  an  infiltrated  base,  and  exhibits 
no  copper-colored  areola. 

It  is  mainly  by  the  presence  or  the  absence  of  associated  signs  of  S3^hilis 
that  a  diagnosis  is  to  be  made. 

Large,  Flat  Pustular  Syphilide. — The  lesions  of  this  syphilide  closely 
resemble  ecthyma;  hence  the  eruption  is  commonly  called  syphilitic  ecthyma. 
It  appears  in  the  form  of  large,  flat  pustules,  varying  from  a  quarter  of  an 
inch  to  an  inch  and  a  half  in  diameter   (Fig.  399).     The  lesion  commonly 


Fig.  395. 

Pustular  syphilide  (pustulo-crustaceous) . 


Pig.  396. 
(From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


begins  as  a  raised,  dusky  red,  slightly  inflamed,  and  indurated  area,  which 
quickly  suppurates,  the  pus  raising  the  epiderm  but  slightly,  and  forming  a 
large,  flat,  not  very  tense  pustule,  which  shortly  crusts. 

The  lesion  may  remain  superficial,  limited,  and  only  moderately  crusted, 
exposing,  on  exfoliation  or  removal  of  the  scab,  an  erosion  or  a  shallow  ulcera- 
tion, or  it  may  extend  both  in  depth  and  in  circumference. 

The  superficial  form  occurs  towards  the  end  of  the  first  year  of  constitu- 
tional syphilis;  it  is  amenable  to  treatment,  and  particularly  affects  the  shoul- 
ders, back,  and  extremities. 


742 


GENITO-URINARY  SURGERY 


In  the  deep  form  of  syphilitic  ecthyma  the  ulceration  is  progressive  in  all 
directions.  The  crust  increases  in  thickness  and  extent,  the  material  for  it 
being  furnished  in  the  continued  suppuration  of  the  extending  ulcer;  it  pro- 
jects from  the  surface  in  the  form  of  a  greenish  or  brown-black  cone,  often 
exhibiting  distinct  stratification.  This  thick,  conical,  adherent  crust  com- 
monly overlaps  the  raw  surface  beneath;  sometimes  its  base  is  sunk  in  the 
ulcer  and  is  completely  surrounded  by  unhealthy  granulations. 

Lesions  made  up  of  these  dark,  raised,  conical,  laminated  crusts,  seated 
upon  deep  ulcers,  and  surrounded  by  reddened,  indurated  areas,  are  called 
rupial.  When  the  ulceration  extends  laterally  and  does  not  grow  materially 
deeper,  the  crust  may  be  depressed  in  the  centre  and  elevated  about  the 
margins. 


Fig.    397. — Pustular    syphilide.      (From    the    collection  i 

of  photographs  of  Dr.  George  Henry  Fox.) 

When  the  thick  crusts  of  deep  ecthyma  are  removed,  punched-out  ulcers 
covered  with  thick  greenish  or  yellow  pus  are  found.  These  ulcers  are  rounded 
or  circular,  and  usually  discrete  and  few  in  number.  When  the  pustules  are 
closely  grouped  they  commonly  become  confluent,  the  outline  of  the  resultant 
lesion   being  circinate. 

The  chronic  crusted  lesions  of  the  pustular  syphilides  are  termed  pustulo- 
crustaceous.  When  they  are  confluent,  spreading  widely  in  circinate  forms, 
and  are  destructive,  they  are  termed  serpiginous  (Fig.  400). 

Diagnosis. — The  diagnosis  of  syphilitic  ecthyma  from  simple  ecthyma  will 
be  based  largely  upon  the  evolution  of  the  lesions,  which  in  non-specific  dis- 
ease develop  rapidly  and  run  their  course  in  a  few  weeks,  are  attended  with 


SYPHILIS 


743 


«v^ 


Pj(j_  398. — Flat  pustular  and  papulo-squamous  syphilide. 


744 


GENITO-URIXARY  SURGERY 


heat,  pain,  and  other  symptoms  of  acute  inflammation,  form  brownish,  not 
very  thick,  laminated  crusts,  and  exhibit  on  removal  of  the  latter  superficial 
ulceration  in  place  of  the  punched-out  unhealthy  ulcer  of  syphilis.  In  ecthyma 
the  eruption  is  uniform,  and  there  are  no  coexistent  signs  of  syphilis. 

Deep  ecthyma  leaves  permanent  cicatrices.     Rupial  and  the  other  forms 
of  deep  syphilitic  ecthyma  appear  as  late  lesions  of  syphilis. 


Fig.  399. — Large,  flat 
pustular  syphilide  (ecthy- 
ma). (From  the  collec- 
tion of  photographs  of 
Dr.  George  Henry  Fox.) 


Fig.   403. — Serpiginous  syphilide.      (From  the  collection  of  photo- 
graphs of  Dr.  George  Henry  Fox.) 


All  the  late  pustular  eruptions,  particular^  those  which  are  deep,  yield  to 
specific  treatment  slowly.  They  usually  develop  in  the  cachectic  and  poorly 
nourished,  and  indicate  tonic  supporting  treatment  in  addition  to  specific 
medication  and  local  applications. 

Pigmentary  Syphilide. — The  pigmentary  syphilides  are  quite  distinct 
from  the  stains  secondary  to  the  papular  or  pustular  eruption  of  svphilis.  They 
are  dependent  upon  a  primary  excess  of  pigment,  which  may  subsequently 
give  place  to  leucoderma,  or  loss  of  color.  The  lesion  appears  in  three  forms 
(Taylor) : 


SYPHILIS  745 

1.  As  rounded,  oval,  or  irregular  plaques,  with  sharply  defined  or  jagged 
borders,  varying  from  light  brown  to  deep  brown. 

2.  As  diffuse  pigmentation,  which  becomes  the  seat  of  leucodermatous 
changes,  appearing  first  as  small  spots,  which  gradually  increase  in  size  (reti- 
form  pigmentation). 

3.  As  abnormal  distribution  of  pigment,  some  parts  of  the  skin  appearing 
lighter,  others  darker,  than  normal  (marbled  pigmentation). 

The  pigmentation  is  unaffected  by  pressure,  the  patches  are  not  above 
the  surface  of  the  surrounding  skin,  and  there  is  no  exfoliation.  It  is  usually 
a  secondary  manifestation  of  the  disease,  developing  about  the  sixth  month, 
though  it  is  at  times  observed  as  late  as  the  second  or  the  third  year.  It  is 
more  common  in  females  before  middle  age.  Its  seats  of  preference  are  the 
sides  of  the  neck,  though  it  may  be  found  elsewhere,  as  the  chest,  the  fore- 
head, and  the  flexor  surfaces  of  the  limbs.  It  lasts  for  several  months,  then 
gradually  fades,  the  skin  resuming  its  natural  color.  Treatment  seems  to  have 
no  effect  upon  it. 

Tubercular  Syphilide. — Tubercular  syphilides  appear  as  pin-head-  or 
almond-sized,  rounded  or  flat,  hard,  copper-colored  infiltrations,  which  invade 


Fig.  401. — Non-ulcerating  tubercular  syphilide.     (From  the  collection  of  photographs  of  Dr.  George 

Henry  Fox.) 

the  entire  thickness  of  the  skin,  •  differing  in  this  respect  from  the  papular 
eruption,  and  resembling,  except  in  the  absence  of  acute  inflammatory  symp- 
toms, a  forming  furuncle. 

The  eruption  may  be  generalized,  or  may  occur  in  patches  on  certain  parts 
of  the  body;  it  may  be  discrete  or  confluent;  it  may  be  circinate,  serpiginous, 
or  irregularly  grouped.  It  may  ulcerate,  or  the  infiltrate  may  become  absorbed. 
In  either  case  there  is  usually  permanent  scarring. 

A  discrete  general  eruption  is  rare;  it  occurs  in  the  late  secondary  or  in 
the  tertiary  period  of  the  disease,  rarely  before  the  end  of  the  first  year,  though 
exceptionally  it  may  develop  within  six  months  of  the  chancre. 

The  eruption  commonly  appears  grouped  on  one  or  more  regions  of  the 
body,  the  indurated  lesions  having  a  tendency  to  coalesce  and  form  circular^ 
scaling,  or,  if  ulceration  takes  place,  eroding  patches.     Lesions  of  this  kind 


746 


GENITO-URINARY  SURGERY 


may  develop  twenty,  thirty,  or  forty  years  after  the  appearance  of  a  chancre 
(Bassereau). 


Fig.  402. — Xon-ulcerating  tubercular  syphilide.     (From  the  collection  of  photographs  of  Dr. 

George  Henry  Fox.) 


Fig.    403. — Tubercular    (squamous)    syphilide.      CFrom   the   coi'.ectior    of   photographs    of 
Dr.  George  Henry  Fox.) 

Though  the  tubercular  syphilide  may  attack  any  portion  of  the  skin  sur- 
face, its  seats  of  preference  are  the  face,  particularly  about  the  lips  and  nose, 
the  forehead,  the  ears,  the  back,  and  the  legs.  The  course  of  this  eruption 
is  extremely  chronic;  it  is  prone  to  relapse. 

The   Non-Ulcerating   Tubercular   Syphilide. — The    hard,    dusky    red, 


SYPHILIS 


747 


chronic,  scaling,  tubercular  eruption,  when  general  and  discrete,  cannot  well 
be  confounded  with  any  other  lesion,  except  the  papular  S3^hilide;  an  error 
of  no  great  moment,  but  one  which  is  avoided  by  noting  that  the  tubercle 
involves  the  entire  thickness  of  the  skin  and  appears  at  a  later  stage  of  the 
disease  than  does  the  papule.  When  grouped,  the  individual  lesions  of  each 
group  are  usually  much  smaller  than  the  lesions  of  the  discrete  general  erup- 
tion; they  tend  to  coalesce,  forming  circular  or  irregular  patches  (Fig.  401), 
which  increase  in  size  peripherally,  while  absorption  and  more  or  less  atrophy 


Fig.  404. — Tubercular  syphilide.     (From  the  collection  of  photographs 
of  Dr.  George  Henry  Fox.) 

of  the  skin  take  place  in  the  centre.  This  results  in  a  raised  circular  mar- 
gin made  up  of  tubercles  so  merged  that  they  can  rarely  be  distinguished 
as  separate  tumors,  within  which  lies  the  depressed,  pigmented,  atrophic 
skin  ( Fig.  402 ) .  These  circles  vary  in  diameter  from  a  fraction  of  an  inch 
to  four  or  five  inches.  The  surface  of  the  non-ulcerating  tubercle  may  be 
dry  and  glistening.  More  commonly  there  is  a  covering  of  branny  scales 
(tuberculo-squamous  syphilide)  (Fig.  403).  These  lesions  develop  with- 
out subjective  sensations,   except  when   situated   upon   the   face.     After   an 


748 


GENITO-URINARY  SURGERY 


alcoholic  debauch  there  may  be  marked  local  inflammatory  phenomena  ia 
lesions  thus  situated. 

The  tubercles  are  resistant  to  treatment,  often  lasting  for  months.  They 
may  form  permanent  scars,  incident  to  a  process  of  interstitial  absorption. 
These  scars  are  at  first  brown  or  copper-colored;  ultimately  they  become 
white. 

Ulcerating  tubercular  syphilides  are  much  more  serious  than  the  dry 
tubercular  eruption,  both  in  their  immediate  effects  and  from  a  prognostic 


Fig.  405. — Tubercular  syphilide.     (From  the  collection  of  photo- 
graphs of  Dr.  George  Henry  Fox.) 

Standpoint.  The  dry  lesion  after  persisting  for  months  may  break  down; 
more  commonly  the  tubercle  from  the  first  shows  a  tendency  to  crust.  This 
form  of  eruption  is  rarely  general,  commonly  affects  certain  regions  of  the 
body,  exhibits  a  round  grouping,  and  may  invade  a  large  surface. 

The  ulceration  may  be  superficial,  attended  by  a  slight  scabbing  and 
followed  by  very  little  scarring;  or  it  may  be  deep,  invading  the  entire  thick- 
ness of  the  skin  (Plate  XVIII),  may  be  covered  by  thick  scabs  (Fig.  404), 
and  may  be  followed  by  dense  cicatrices,  which  cause  both  disfigurement  and 
disability. 


PLATE  XVIII. 


Ulci-r:'/ i;  ii  tubercular  s\"philide. 


SYPHILIS 


749 


The  ulceration  extends  slowly,  healing  with  the  formation  of  scar-tissue 
in  one  place  while  breaking  down  is  taking  place  in  another.  This  process 
may  continue  for  months  or  years,  the  diseased  area  forming  circles,  broad 
bands,  or  irregular  figures  (Fig.  405),  and  involving  a  large  surface.  Thus 
the  entire  face  may  be  disfigured  by  the  lesion.  This  form  is  called  serpiginous. 
It  is,  of  course,  not  exempt  from  the  microbic  invasion  to  which  all  open 
surfaces  are  exposed,  and  as  a- result  of  infection  may  become  phagedaenic, 
the  ulceration  extending  with  extreme  rapidity  and  destroying  a  large  amount 
of  tissue  in  a  few  hours. 

The  face  and  back  are  the  favorite  seats  of  serpiginous  syphilides. 

As  in  other  forms  of  syphilitic  skin  eruptions,  in  place  of  ulceration  and 
destruction  there  may  be  hypertrophy,  the  skin  papillae  growing  from  the  ulcer- 
ated surface  of  a  tubercle  to  form  a  pus-secreting  cauliflower  growth. 

Frequently  the  cicatrices  of  ulcerating  tubercular  s^-philides  are  pathogno- 
monic of  the  specific  lesions;  in  the  midst  of  the  large  scars  can  be  seen  the 
small,  depressed,  round  cicatrices  of  individual  tubercles. 

Diagnosis. — The  diagnosis  of  the  tubercular  syphilide  must  be  made  from 
lupus  vulgaris.  Lepra  and  carcinoma  are  also  closely  simulated  by  this  syph- 
ilide. 

The  main  diagnostic  points  between  ulcerating  tubercular  syphilide  and  lupus 
vulgaris  are  as  follows: 


Tubercular  Syphilide. 

Tubercular  syphilide  generally  occurs 
in  adults  who  give  a  history  of  syph- 
ilis or  exhibit  signs  of  other  syphilitic 
lesions. 

Begins  as  a  copper-colored  or  brownish 
tubercle,  which  becomes  a  character- 
istic  ulcer   in  one   or  two  months. 

The  tubercles  are  of  a  brownish-red  or 
coppery  color,  and  are  comparatively 
large. 

The  skin  is  distinctly  infiltrated  through 
its    entire   thickness. 

Ulcers,  if  distinct,  are  small,  circular, 
punched  out.  If  confluent,  they  in- 
volve a  large  area.  The  secretion 
may  be  copious  and  offensive. 

The   crusts    are  bulky   and   greenish   or 

brownish   black. 
The    scabs   are    irregular   in   shape   and 

attachment. 


The  scars  are  soft,  white,  and  circular. 
Local  treatment  is  ineffective.  Inter- 
nal soecific  treatment  effects  a  cure. 


Lupus    J'ulgaris. 

Lupus  vulgaris  generally  occurs,  or  at 
least  first  appears,  before  the  twen- 
tieth year  of  life,  without  history  or 
signs  of  syphilis. 

Begins  as  a  tubercle,  which  does  not 
ulcerate  to  the  same  extent  for  many 
months  or  even  years. 

The  tubercles  are  often  translucent,  of 
lighter  color,  and  are  small. 

The  infiltration  of  the  skin  is  not  so 
marked. 

Ulcers  are  rarely  distinct.  They  are 
superficial,  are  not  punched  out,  ex- 
hibit no  regular  form,  and  seldom  in- 
volve large  areas.  The  secretion  is 
slight  and  not  offensive. 

The  crusts  are  thin  and  dark  red. 

The  scabs  are  arranged  more  regularly, 
attached  in  the  centre,  and  loosened 
at  the  edges. 

The  scars  are  distorted,  irregular,  and 
puckered.  Active  surgical  interven- 
tion is  effective.  Internal  specific 
treatment  is  without  effect. 


Aside  from  the  history  of  the  case,  the  most  important  points  to  be  con- 
sidered in  differentiating  between  lupus  and  sj-philis  are  the  early  age  at 
which  lupus  begins,  its  very  slow  course,  its  superficial  ulcerations,   and  its 


750  GENITO-URINARY  SURGERY 

cicatrices,  which  exhibit  neither  the  characteristic  coppery  stains  nor  the 
many  small,  depressed,  circular  scars  of  ulcerating  tubercular  syphilides. 

Cancer  is  sometimes  closely  simulated  by  the  tubercular  syphilide.  The 
slow  growth,  the  steady  progress  without  attempt  at  cicatrization,  the  scanty 
discharge,  the  lancinating  pains,  the  lymphatic  involvement,  the  absence  of 
signs  or  history  of  syphilis,  and  the  resistance  to  specific  treatment,  are 
symptoms  which  will  generally  lead  to  a  correct  diagnosis. 

The  Bullous  SYPHiLroE. — This  eruption  usually  appears  as  rounded  or 
oval,  discrete  blebs  surrounded  by  a  slight  areola,  varying  in  size  from  that 
of  a  split  pea  to  that  of  a  penny.  The  clear  serum  contained  within  the  bleb 
shortly  becomes  turbid  and  blood-stained  or  even  distinctly  purulent.  On 
rupture  of  the  blebs,  the  contents  form  dark-yellowish  or  greenish-black  scabs. 
These,  growing  from  the  bottom,  by  the  drying  of  the  freshly  secreted  pus  of 
the  slowly  enlarging  ulcer,  finally  result  in  raised,  conical,  imbricated  crusts, 
often  half  an  inch  to  an  inch  in  height,  and  sometimes  twice  as  much  in 
diameter  (Fig.  406).  These  crusts  are  adherent,  and  usually  overlap  and 
conceal  the  underlying  ulcer,  though  sometimes  they  may  be  set  in  the  latter 
as  a  watch-crystal  is  set  in  its  rim.  Unless  mechanically  disturbed,  they 
generally  remain  till  the  ulcer  is  healed.  If  they  are  removed,  a  deep,  punched- 
out,  unhealthy,  granulating  surface  is  exposed,  covered  with  sanious  pus. 

The  bullous  syphiloderm  is  commonly  found  in  broken-down  subjects,  and 
is  significant  of  an  inveterate  form  of  syphilitic  poisoning.  The  crusted  ulcers 
following  bullae  or  pustules  form  the  typical  rupial  lesions.  The  crusts  of 
their  rupia  are  large,  and  are  thicker  and  darker  than  those  of  any  of  the  other 
syphilides.  The  ulceration  involves  the  entire  thickness  of  the  skin,  and  often 
extends  over  a  large  surface. 

The  scars  left  by  rupia  are  similar  to  those  of  deep  ecthyma.  The  erup- 
tion is  encountered  in  the  tertiary  stage  of  the  disease,  and  is  one  of  the  most 
characteristic  lesions  of  syphilis. 

The  Gummatous  Syphilide. — Though  gummata  of  the  skin  exceptionally 
appear  in  the  first  six  months  of  syphilis,  in  such  cases  indicating  a  grave 
form  of  the  disease,  they  commonly  develop  three  or  four  years  after  the 
chancre. 

Gumma  differs  from  the  lesions  already  described  in  the  fact  that  it  is 
a  true  tumor  or  granuloma,  which,  having  once  developed,  in  whatever  way 
it  terminates  permanently,  affects  the  seat  of  invasion. 

The  favorite  localities  of  the  gummatous  syphilides  are  the  face  (particu- 
larly the  forehead),  arms,  forearms,  the  anterior  surface  of  the  leg  (particu- 
larly the  upper  third),  the  skin  overlying  the  sternum  and  clavicle,  the  scrotum, 
the  penis,  the  external  genitalia  of  women. 

Gummata  of  the  skin  commonly  appear  as  rounded,  painless,  subcutaneous 
nodules,  freely  movable,  and  varying  in  size  from  that  of  a  pea  to  that  of  a 
cherry.  These  slowly  grow,  reddening,  infiltrating,  and  softening  the  super- 
ficial layers  of  the  skin  and  breaking  down  to  form  deep,  undermined,  slough- 
sloughing  ulcers  (Figs.  407,  408,  and  409).  Sometimes  the  gumma  begins 
as  a  circumscribed  infiltration  of  the  skin  instead  of  a  distinct  subcutaneous 
tumor. 


SYPHILIS 


751 


Fig.  406. — Syphilitic  rupia  following  the  bullous  syphilide. 


752 


GENITO-URINARY  SURGERY 


The  gumma  goes  through  the  stages  of:  1.  Formation,  usually  of  long 
duration  and  unattended  by  pain.  2.  Softening,  fluctuation  being  felt  when 
the  tumor  has  reached  its  full  size  (from  that  of  an  almond  to  that  of  a 
hen's  egg).  3.  Ulceration;  the  skin  becomes  discolored  and  perforated,  and 
a  small  quantity  of  puriform,  gummy  liquid  is  discharged.  4.  Reparation;  after 
extrusion  of  the  slough  granulations  form,  growing  centrally  from  the  periphery 
of  the  ulcer. 

When  the  gumma  opens  there  is  at  once  an  escape  of  mucilaginous  liquid. 
The  partially  disorganized  infiltrate  adheres  by  its  deeper  portions  to  the 
subcutaneous  cellular  tissue,  and  is  subsequently  thrown  off  in  the  form  of 
sloughs.  By  the  process  of  ulceration  a  number  of  contiguous  gummata  may 
coalesce,  forming  one  huge  cavity,  with  irregular  sloughing  walls. 


Fig.  407. — Gummatous  syphilide.     (From  the  collection  of  photographs  of  Dr.  George  Henry  Fox.) 


Though  the  stage  of  formation  is  slow  and  painless,  the  patient  often 
noticing  the  tumor  only  by  accident,  softening  and  ulceration  may  progress 
with  great  rapidity.  Thus,  Bassereau  states  that  a  smair,  indolent,  subcutaneous 
nodule  of  the  nose  or  ear  has  in  a  single  night  undergone  extensive  destructive 
ulceration,  producing  permanent  disfigurement. 

The  gumma  may  be  single  or  multiple.  In  the  latter  case  there  are  rarely 
more  than  half  a  dozen  (Fig.  410).  Exceptionally  several  dozen  may  develop, 
either  simultaneously  or  following  one  another,  usually  showing  a  circular  or 
circinate  grouping  and  exhibiting  a  tendency  to  coalesce,  forming  a  diffuse 
infiltration,  which  on  ulceration  may  discharge  by  several  openings  through 
the  blue  undermined  skin. 

The  middle  of  the  forehead  is  a  favorite  seat  of  gummata.  One  or  several 
nodules  may  develop.  They  commonly  involve  the  underlying  bone,  producing 
caries,  which  may  extend  through  its  entire  thickness,  exposing  the  dura. 

Exceptionally  there  develops  a  deep  and  diffuse  infiltration  of  Ihe  face, 
causing  a  great  thickening  of  the  skin  and  presenting  the  appearance  of  leonti- 
asis.  Acute  inflammation  of  this  infiltrate  is  especially  liable  to  occur  in 
drunkards,  and  leads  to  extensive  destruction  of  tissue  and  consequent  deform- 


SYPHILIS 


753 


ity,  and  exceptionally  to  violent  hemorrhage  from  erosion  of  blood-vessels. 
These  gummatous  infiltrations  are  sometimes  transformed  to  tuberculous  or 
cancerous  lesions. 

Gummata  of  the  extremities  may  be  single  or  multiple.     As  they  appear 
on  the  leg  they  are  commonly  multiple,  and  have  for  their  seats  of  predilection 


Fig.  408. — Single  ulcerating  gumma. 


Fig.  409. — Ulcerating  gummata  becoming  con- 
fluent. (From  the  collection  of  photographs  of 
Dr.  George  Henry  Fox.) 


the  anterior  and  lateral  surfaces  of  the  upper  third  and  the  malleolar  regions. 
When  placed  here  they  break  down  readily  and  are  subject  to  mixed  infec- 
tion (Fig.  411).  They  are  extremely  obstinate  to  treatment,  and  ultimately 
assume  the  chronic  indurated  appearance  of  ulcers  due  to  other  causes,  par- 
ticularly when  they  are  near  the  malleoli  (Fig.  412).  Gummatous  syphilides 
when  they  develop  over  the  clavicle  and  sternum  are  often  associated  with 
48 


754 


GENITO-URINARY  SURGERY 


underlying  periostitis  and  ostitis.     Because  of  this,  when  they  have  ulcerated 
they  are  difficult  to  cure. 

The  prepuce  may  be  affected  by  either  diffuse  gummatous  infiltration  or 
individual  nodules.  In  either  case  the  diagnosis  from  primary  lesion  can  be 
made  from  the  fact  that  infiltration  preceded  ulceration.  Single  ulcerating 
gummatous  lesions  of  the  glans  penis  may  exactly  simulate  chancre.  The 
inguinal  lymph-nodes  do  not,  however,  share  the  characteristic  enlargement  of 


-X 


Fig.  410. — Multiple  gummata  of  the  leg.     (From  the  collection  of  photographs 
of  Dr.  George  Henry  Fox.) 

the  primary  lesion,  and  the  development  of  the  lesion  and  the  history  of  the 
case  usually  point  to  the  true  diagnosis. 

The  gummatous  ulcer  may  become  serpiginous  or  phagedaenic.  The  necrosis 
involves  not  only  the  imperfectly  organized,  round-celled  infiltrate  of  gumma, 
but  also  the  anatomically  associated  tissues,  often  exposing  and  eroding  bone, 
destroying  tendons  and  muscles,  opening  mucous  channels,  and  resulting  in 
disfiguring  and  disabling  cicatrices.  In  the  scrofulous,  gummatous  ulcers  are 
particularly  persistent.     Exceptionally  these  ulcers  exhibit  papillary  outcrop- 


SYPHILIS 


755 


pings  presenting  an  appearance  much  like  that  of  epithelioma.    From  the  scars 
of  these  ulcers  epitheliomata  sometimes  develop. 

Diagnosis. — A  history  of  syphilis,  or  concomitant  signs  of  the  disease, 
and  the  typical  development  of  a  painless  infiltration  at  a  seat  of  predilection, 
should  establish  the  diagnosis  of  gumma.  As  this  lesion  is  a  late  tertiary  symp- 
tom, it  may  stand  alone  as  an  expression  of  the  constitutional  disease,  since 
too  often  a  clear  history  is  wanting  both  of  preceding  S3^hilis  and  of  the 
mode  of  onset  of  the  gumma.  When  the  tumor  is  seen  during  the  stage  of 
infiltration  it  may  simulate  benign  tumor  or  sarcoma  so. closely  that  diagnosis 
can  be  made  only  by  the  therapeutic  test  or  by  keeping  the  growth  under 


.»«•' 


J 

Fig.  411. — Sloughing  gumma  of  the  leg. 

observation  a  sufficient  length  of  time  to  note  its  mode  of  development.  The 
alleged  cure  of  sarcoma  by  mercury  clearly  shows  the  difficulty  in  making  a 
correct  diagnosis  from  one  examination. 

When  the  gumma  has  ulcerated  and  exhibits  papillary  outgrowths  it  may 
resemble  epithelioma  almost  exactly.  The  mode  of  onset  is,  however,  different, 
epithelioma  beginning  as  a  wart  or  an  ulcer,  and  not  as  an  infiltration.  Micro- 
scopical examination  of  a  portion  of  the  removed  growth  and  the  effect  of 
specific  treatment  should  definitely  and  promptly  settle  the  diagnosis. 

The  cicatrices  of  healed  gummata  are  depressed  and  adherent  to  deeper 
structures. 


756 


GENITO-URIXARY  SURGERY 


SYPHILITIC  AFFECTIONS  OF  THE  APPENDAGES  OF  THE  SKIN 

Syphilitic  Alopecia  and  Onychia. — Syphilitic  alopecia  appears  with  the 
early  secondary  symptoms — i.e.,  about  the  third  month  from  the  development 
of  the  chancre;  it  may  develop  much  later.  There  may  be  total  or  partial  loss 
of  the  hair.  Total  loss  is  rare.  Partial  loss  may  develop  in  the  form  of  a 
general  shedding,  the  hair  coming  out  readily  and  the  resultant  appearance  of 
the  scalp  simulating  that  of  advanced  baldness  from  other  causes.  More 
characteristic  is  the  shedding  of  hair  in  irregular,  usually   rounded,   scaling 


Fig.  412. 


-Ulcerating  gummata  of  the  malleolar  region.     (From  the  collection  of  photo- 
graphs of  Dr.  George  Henry  Fox.) 


patches,  giving  the  scalp  a  typical  moth-eaten  appearance.  Both  the  general 
and  the  circumscribed  alopecia  are  often  associated  with  papular  and  papulo- 
pustular  lesions  of  the  scalp.  As  has  been  stated,  the  prognosis  of  these  forms 
of  alopecia  is  usually  favorable,  the  hairs  growing  again  on  the  absorption 
of  the  infiltrate  v/hich  interferes  with  their  nutrition. 

Circumscribed  alopecia  due  to  ulcerating  and  tubercular  syphilides  is  per- 
manent, since  the  lesions  entirely  destroy  the  hair-follicles  (Fig.  413). 

The  diagnosis  of  specific  alopecia  is  founded  on  the  rapidity  of  the  process., 
the  history  of  syphilis  and  associated  symptoms  of  the  disease,  and  the  patchy, 
moth-eaten  appearance  of  the  scalp,  the  bare  spots  showing  prominent  follicles 


SYPHILIS 


757 


and  a  scaling  surface.  When  the  alopecia  is  partial,  shedding  of  the  hair  is 
most  noticed  over  the  posterior  portions  of  the  scalp,  thus  differing  from  ordi- 
nary baldness. 

In  addition  to  vigorous  constitutional  treatment,  shampooing,  massage,  and 
active  counter-irritation  are  indicated. 

Onychia  is  an  expression  of  the  influence  of  the  syphilitic  poison  on  the  ma- 
trix of  the  nail  and  on  the  periungual  and  subungual  epidermic  tissue.  The  nails 
may  become  dry,  brittle,  lustreless,  and  break  on  the  least  pressure  (friable 
onychia).     They  may  be  fissured  and  loosened  from  their  matrices,  to  be 


Pig.  413. — Syphilitic  alopecia  following  ulcer- 
ative lesions.  (From  the  collection  of  photographs  of 
Dr.  George  Henry  Fox.) 

finally  shed  completely,  giving  place  to  a  new  nail.  Sometimes  the  nail  be- 
comes greatly  discolored,  thickened,  and  distorted   (onychia  hypertrophica). 

These  forms  of  onychia  are  usually  observed  in  the  early  secondary  period 
of  syphilis.  They  are  painless,  non-inflammatory,  and  produce  no  permanent 
deformity,  the  new  nail-tissue  being  healthy  in  appearance  when  active  con- 
stitutional treatment  has  succeeded  in  overcoming  the  specific  virus.  The  nails 
of  the  fingers  are  more  frequently  attacked  than  those  of  the  toes. 

Paronychia  may  develop  as  an  indolent  persistent  inflammation  which 
may  be  dry  or  moist. 

The  dry  paronychia,  or  non-ulcerative  form  of  the  affection,  is  commonly 


758  GENITO-URINARY  SURGERY 

associated  with  the  papular  syphilides.  It  begins  either  as  a  papule  which 
involves  the  cutaneous  folds,  occasioning  horny  thickening  and  exfoliation 
of  the  epidermis,  or  as  an  infiltration  surrounding  the  nail,  much  as  would 
an  ordinary  "run-around,"  except  that  it  is  chronic  in  its  course,  painless,  and 
exhibits  a  deep  coppery  color.  In  either  case  the  nail  is  often  brittle,  cracked, 
and  deformed. 

Moist  paronychia,  or  the  ulcerating  form  of  the  affection,  is  often  asso- 
ciated with  the  vesicular  or  pustular  syphilides.  It  begins  as  in  the  dry  form, 
but  goes  on  to  ulceration,  the  infiltrate  becoming  fissured  and  suppurating. 
As  a  result  there  is  found  about  the  periphery  of  the  nail,  and  frequently 
undermining  it,  an  unhealthy  ulcer,  the  granulations  of  which  may  become 
exuberant.  There  may  be  swelling  of  the  extremity  of  the  digit  as  marked 
as  that  observed  in  felon.  The  digital  chancre  may  closely  simulate  a  moist 
paronychia.     It  is  usually  more  acute  in  its  course  and  is  distinctly  painful. 

Diagnosis. — The  diagnosis  of  syphilitic  paronychia  is  founded  on  the  pain- 
less, chronic  course  of  the  affection,  the  absence  of  acute  inflammatory  symp- 
toms, and  the  presence  of  other  signs  of  syphilis. 

The  nail  is  frequently  shed,  and,  if  the  ulceration  has  been  sufficiently  deep 
to  destroy  the  matrix,  will  not  be  reproduced.  It  usually  grows  again,  but  is 
shrivelled  and  deformed.    The  infiltrate  may  remain  for  many  months. 

Treatment. — The  treatment  of  ulcerating  paronychia  is  primarily  that 
suited  to  the  management  of  secondary  syphilis.  The  local  treatment  must  be 
conducted  on  general  surgical  principles.  Prolonged  immersion  in  weak,^  hot 
bichloride  solution  (1  to  2000),  follov/ed  by  the  application  of  moist  com- 
presses wrung  out  of  the  same  solution  and  kept  from  drying  by  the  appli- 
cation of  waxed  paper  or  oiled  silk,  will  aid  in  rendering  the  ulcerating  sur- 
face clean  and  will  promote  healing. 

^Vhen  the  granulations  are  indolent  and  exuberant,  forming  a  mushroom- 
like growth,  they  may  be  thoroughly  curetted,  or  their  surface  may  be  sprinkled 
with  dry  powdered  lead  nitrate,  an  ordinary  gauze  dressing  being  applied  over 
this.  When  ulceration  has  undermined  the  nail,  the  latter  should  be  trimmed 
away  sufficiently  to  allow  thorough  local  treatment  to  be  applied  to  the  entire 
diseased  surface.  Iodoform  and  aristol  are  both  useful  applications,  but  only 
when  they  are  brought  in  direct  contact  with  the  ulcer.  When  cicatrization  has 
taken  place,  careful  strapping  with  thin  strips  of  resin  adhesive  plaster,  re- 
peated daily,  will  encourage  the  formation  of  a  symmetrical  nail. 


CHAPTER  XXXVI 

SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES 
AND  ALIMENTARY  TRACT 

The  mucous  membrane  manifestations  of  syphilis  correspond  in  pathology 
and  general  features  with  those  appearing  on  the  skin,  the  difference  depend- 
ing upon  increased  vascularity,  diminished  resistance  to  extension  and  ulcera- 
tion on  the  part  of  the  surrounding  macerated  mucous  membrane,  and  a  greater 
or  less  degree  of  irritation  incident  to  secretions  which  are  constantly  brought 
in  contact  with  the  lesions. 

Erythematous  Syphilide. — This  attacks  the  throat,  the  vagina,  the  urethra, 
the  glans  penis,  and  the  inner  surface  of  the  foreskin.  It  may  develop  on  any 
mucous  surface  of  the  respiratory,  digestive,  or  genito-urinary  tract.  As  in 
the  case  of  the  corresponding  skin  eruption,  the  lesions  first  appear  as  discrete 
spots;  these  become  confluent  in  a  few  hours,  exhibiting  then  a  somewhat  sharply 
circumscribed  circinate  margin. 

The  mucous  membrane  of  the  throat  is  most  frequently  attacked,  the  patient 
suffering  from  syphilitic  angina,  which  may  assume  the  acute  or  the  chronic 
form.  The  hyperaemia  and  oedema  involve  the  pharynx,  tonsils,  half-arches, 
and  soft  palate,  but  rarely  extend  to  the  hard  palate,  though  the  latter  may 
exhibit  discrete  macules. 

So  quickly  does  the  macular  eruption  of  the  mucous  membrane  become 
confluent  that,  when  first  observed,  the  lesions  depending  upon  their  location 
closely  simulate  simple  sore  throat,  balanoposthitis,  vaginitis,  or  urethritis.  It 
is  most  important  to  recognize  the  syphihtic  nature  of  such  lesions,  since  they 
may  appear  before  other  more  characteristic  secondary  symptoms,  or  as  the 
only  manifestation  of  the  disease,  and  since  their  discharges  are  contagious. 

Diagnosis. — The  diagnosis  will  usually  be  founded  on  associated  signs  or 
symptoms  of  syphilis,  and  on  the  absence  of  a  cause  for  simple  inflammation. 
There  is  nothing  typical  or  characteristic  in  the  local  appearance. 

Papular  Syphilide. — The  papular  eruption  upon  the  mucous  membranes 
may  appear  as  a  denudation  or  erosion,  as  a  circumscribed  diphtheroid  patch, 
as  a  vegetating  papule,  as  a  superficial  ulceration,  or  as  a  scaly  patch.  These 
lesions  are  more  prone  to  recur  than  the  homologous  lesions  of  the  skin,  and  are 
more  obstinate  to  treatment. 

They  are  exactly  simulated  by  the  papular  syphilide,  as  it  develops  about 
the  mucous  orifices,  on  the  scrotum,  beneath  the  breasts,  or  in  any  region  where 
heat,  moisture,  and  friction  modify  the  eruption. 

All  forms  of  papular  eruption  are  classed  under  the  general  heading  of 
mucous  patches,  though  this  term  is  often  limited  to  lesions  covered  by  a 
gray-white  pseudo-membrane  or  to  the  later  scaly  eruption  of  the  mucous 
membrane. 

The  papular  erosion  appears  in  the  form  of  oval  or  rounded,  small  or 
large,  infiltrated  patches,  exhibiting  a  raw-ham  color,  denuded  of  epithelial 

759 


760  GENITO-URINARY  SURGERY 

covering,  and  showing  a  smooth,  glistening  surface.  It  is  usually  placed  on 
the  dorsum  of  the  tongue,  and  associated  with  it  are  found  fissures  of  the 
borders  of  the  organ,  and  mucous  patches.  It  is  particularly  common  in  invet- 
erate smokers  and  hard  drinkers;  and,  indeed,  this  is  true  of  all  the  mouth 
lesions  of  syphilis. 

The  diphtheroid  papule,  the  commonest  form  of  the  mucous  patch,  ap- 
pears as  a  small  or  large,  discrete  or  confluent  papule  covered  with  a  tightly 
adherent,  gray-white  pseudo-membrane,  which  on  being  removed  leaves  a 
bleeding  surface.  The  diphtheroid  membrane  is  but  little  elevated  above  the 
level  of  the  surrounding  healthy  surface.  It  is  somewhat  sharply  defined 
from  the  latter  by  a  narrow  hyperaemic  zone  often  exhibiting  the  dusky-red 
coloration  of  syphilitic  lesions.  There  may  be  central  absorption  of  the  in- 
filtrate and  healing  in  this  portion  of  the  lesion  while  there  is  extension  at  the 
periphery,  thus  producing  ring-like  and  serpiginous  figures. 

This  form  of  mucous  patch  is  generally  found  on  the  mucous  membrane 
of  the  cheeks  and  lips  and  at  the  angles  of  the  mouth,  where  it  becomes 
fissured,  on  the  sides,  under  surface,  and  fraenum  of  the  tongue,  on  the  gums, 
and  on  the  soft  palate,  half-arches,  and  tonsils. 

The  lesions  may  be  attended  with  fissuring,  with  superficial  ulceration,  and, 
when  situated  on  the  tonsils,  with  deep  and  destructive  ulceration.  Under 
these  circumstances  they  may  become  extremely  sensitive,  interfering  with 
eating  and  drinking,  even  with  speaking,  and  occasioning  an  annoying  flow  of 
saliva. 

When  the  mucous  patch  is  undergoing  involution,  either  under  the  influ- 
ence of  constitutional  or  local  treatment  or  spontaneously,  and  loses  its  diph- 
theroid covering,  it  presents  the  appearance  of  a  papular  erosion,  then  heals 
over,  exhibiting  a  temporary  pigmentation. 

When  these  diphtheroid  papules  become  distinctly  inflammatory  in  type 
they  may  react  upon  the  anatomically  related  lymphatic  nodes,  producing 
enlargement,   and  in   some  cases,   from  mixed   infection,   suppuration. 

The  vegetating  papule  exhibits  the  tendency  towards  local  hypertrophy 
which  is  sometimes  a  marked  feature  of  syphilitic  lesions. 

The  infiltration  common  to  all  the  lesions  of  syphiUs  is  in  the  case  of  this 
manifestation  of  the  disease  particularly  well  marked;  in  addition,  the  papillae 
of  the  mucous  membrane  are  greatly  hypertrophied ;  there  results  a  raised 
lesion,  which  is  in  reality  an  infiltrated  papilloma,  varying  in  size  from  that 
of  a  split  pea  to  that  of  a  half-walnut. 

The  surface  of  this  lesion  may  be  covered  with  a  gray-white  false  mem- 
brane, or  may  present  an  eroded  appearance.  The  lesions  have  a  marked 
tendency  towards  peripheral  extension,  and  when  several  are  placed  near  to- 
gether these  are  likely  to  become  confluent. 

The  vegetating  papule  is  comparatively  rare  upon  mucous  membranes. 
It  is  commonly  encountered  about  the  vulva  in  women  and  in  the  anal  region 
in  men.  From  infiltration  the  surface  upon  which  these  lesions  are  placed  loses 
its  elasticity,  so  that  rhagades  or  fissures  are  likely  to  occur. 

Superficial  ulcerations  are  frequently  associated  with  the  vegetating  papules; 
these  represent  infiltration  in  which  there  has  been  destruction  of  tissue,  a  dis- 


SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES  761 

tinct,  punchecl-out,  freely  secreting  ulcer  occupying  the  site  of  a  lesion  which 
in  its  early  stages  presented  the  appearance  of  a  vegetating  papule.  This 
ulcerating  lesion  is  more  frequently  encountered  upon  the  skin  than  upon  the 
mucous  membranes. 

Papulo-Squamous  Syphilide. — The  scaly  patches  (mucous  psoriasis,  opa- 
line plaques)  rarely  appear  in  the  course  of  constitutional  syphihs.  They  are 
rounded  or  irregularly  shaped,  flat,  smooth,  bluish-white  patches,  such  as  would 
result  from  lightly  brushing  a  surface  with  strong  silver  nitrate  solution.  The 
white  coloration  is  due  to  changes  in  the  epithelium,  consequent  on  chronic  irri- 
tation and  inflammatory  infiltration.  The  normal  columnar  cells  are  replaced 
by  squamous  epithelium  arranged  in  many  layers,  producing  a  species  of  corni- 
fication  identical  with  that  described  when  considering  the  pathological  changes 
incident  to  chronic  urethritis;  as  the  thickening  is  greatest  at  the  centre  and 
becomes  less  marked  towards  the  periphery,  so  the  color  shades  into  that  of 
the  surrounding  mucous  membrane.  The  thickened  epithelium  is  itself  ad- 
herent to  the  underlying  surface,  but  its  removal  does  not  occasion  bleeding. 
Frequently  the  central  thickened  epithelium,  exfoliates,  while  the  lesion  extends 
peripherally,  leaving  either  a  surface  of  hj^ertrophied  and  infiltrated  papillae,  a 
distinct  erosion,  or  even  healthy  mucous  membrane  surrounded  by  a  white 
ring  of  epithelium.  From  confluence  of  such  patches  curious  markings  are 
sometimes  observed  on  the  tongue. 

This  lesion  is  most  frequently  observed  on  the  buccal  mucous  membrane, 
along  the  alignment  of  the  upper  and  the  lower  teeth  when  the  jaw  is  closed, 
the  patches  usually  being  more  or  less  confluent.  It  also  develops  on  the 
inner  surface  of  the  lips,  and  on  the  dorsum,  sides,  and  under  surface  of  the 
tongue. 

As  with  other  lesions  of  syphilis,  there  is  little  pain  excited  by  white  scaly 
patches,  except  where  they  are  associated  with  fissures  and  ulcerations. 

Unlike  the  other  forms  of  papular  eruption,  the  scaly  patch  usually  de- 
notes a  late  stage  of  the  disease.  It  may  develop  at  any  time  in  the  late 
secondary  and  tertiary  periods,  and  is  usually  exceedingly  obstinate  to  treat- 
ment. 

GuMMATA  may  develop  in  tertiary  syphilis,  both  in  the  mucous  membrane 
and  in  the  submucous  connective  tissue.  They  may  take  the  form  of  diffuse 
infiltrations  or  of  circumscribed  tumors. 

The  mucous  gummata  appear  as  small  tumors,  which  rarely  reach  the  size 
of  a  pea  before  breaking  down,  forming  punched-out,  unhealthy  ulcers,  about 
the  circumference  of  which  is  often  to  be  noted  a  raw-ham-colored  infiltrate. 

These  lesions  peculiarly  affect  the  hard  and  the  soft  palate,  and  often  ex- 
hibit a  serpiginous  grouping  and  a  slow  extension  in  one  direction  while  cicatri- 
zation is  taking  place  in  the  ulcer  which  first  developed. 

The  submucous  gummata  form  larger  tumors  before  breaking  down.  They 
exhibit,  however,  a  marked  tendency  to  soften  towards  the  surface,  producing 
deep,  punched-out  ulcers  with  infiltrated  borders. 

The  ulcerating  gummata  are  responsible  for  the  stenosing  cicatrices  which 
may  develop  in  nearly  any  portion  of  the  alimentary  canal,  though  they  are 
most  frequently  recognized  in  the  oesophagus  and  the  rectum. 


762  GENITO-URINARY  SURGERY 

Diagnosis  of  Mucous  Syphilides. — To  distinguish  the  erosive  and  diph- 
theroid forms  of  the  mucous  patch  from  the  ulcers  of  simple  aphthae  is,  from 
the  appearance  of  the  lesions  alone,  impossible.  Aphthse,  however,  are  gen- 
erally more  tender,  more  liable  to  be  discrete,  develop  in  a  day  or  two,  run 
a  rapid  course,  and,  either  with  or  without  treatment,  are  well  in  a  few 
days. 

The  difficulty  in  diagnosis  is  made  much  greater  by  the  fact  that  it  is 
especially  in  syphilitics  that  aphthous  spots  are  liable  to  develop.  Fournier 
describes  a  recurrent  herpes  which  attacks  the  oral  mucous  membrane  of 
syphilitics,  producing  small  erosions  which  exactly  resemble  mucous  patches. 
This  eruption  develops  some  years  after  a  methodical  course  of  treatment  has 
apparently  eradicated  the  syphilitic  taint.  Specific  treatment  is  absolutely  with- 
out effect,  the  erosions .  disappearing  spontaneously  in  a  few  days  and  recur- 
ring at  irregular  intervals. 

In  making  a  differential  diagnosis  between  the  erosive  and  diphtheroid 
forms  of  mucous  patches,  aphthte,  and  herpetic  lesions,  the  history  of  the  case, 
the  presence  of  other  signs  of  syphilis,  and  the  effect  of  constitutional  treatment 
would  all  lead  to  a  correct  decision. 

The  scaly  patches  (mucous  psoriasis,  opaline  plaques)  can  not  always  be 
distinguished  from  non-specific  leucoplakia  (hyperkeratosis).  The  latter  some- 
times develops  acutely,  particularly  in  women  and  children.  From  the  syphilitic 
lesions  spirochaetes  may  be  recovered. 

The  idiopathic  leucoplakia — i.e.,  that  of  non-syphilitic  drinkers  and  smokers 
— is  even  slower  in  development  than  the  specific  lesion;  the  white  color  and 
the  heaping  up  of  epithelial  cells  are  more  marked  and  irregular;  there  is  not 
the  same  tendency  towards  central  exfoliation,  as  the  lesion  extends  peripherally, 
— hence  the  resultant  ring-like  configuration  is  less  common.  In  leucoplakia 
the  lesions  are  more  often  found  on  the  tongue  and  the  lower  lip,  subjective 
sensations  are  said  to  be  more  marked,  and  specific  treatment  is  absolutely 
without  avail  in  effecting  a  cure. 

The  points  of  difference  by  which  ulcerating  gummatous  lesions  of  the 
mucous  membrane  can  be  distinguished  from  the  tuberculous  and  malignant 
infiltrations  will  be  considered  when  discussing  the  subject  of  gummata  in 
special  regions. 

Treatment. — The  treatment  of  mucous  syphiHdes  is  constitutional  and 
local,  topical  applications  being  much  more  distinctly  indicated  than  is  the 
case  with  skin  lesions,  except  when  the  latter  assume  the  form  of  mucous 
patches. 

Syphilis  of  the  Tongue. — Chancre  is  rare  upon  the  tongue,  but  when 
present  is  usually  at  or  near  the  tip  of  this  organ  (Du  Castel).  It  is  of  the 
erosive  type,  and  presents  no  peculiarities  of  development. 

Roseola  is  rare  and  ephemeral.  It  appears  in  the  form  of  slight  desquama- 
tive stains. 

Mucous  patches  are  of  the  erosive,  diphtheroid,  and  vegetating  types;  the 
last  variety  is  rare.  When  mucous  patches  are  numerous  and  confluent  there 
is  general  swelling  of  the  tongue,  the  latter  showing  on  its  borders  the  im- 
print of  the  teeth.     Mucous  patches  placed  along  the  sides  of  the  tongue — 


SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES  763 

a  favorite  seat — often  exhibit  more  or  less  fissuring,  in  which  case  they  may  be 
accompanied  by  much  pain. 

The  ulcerations  of  secondary  syphilis  are  usually  small  and  superficial,  and 
are  attended  with  few  subjective  symptoms;  even  should  they  become  deep, 
inflammatory  symptoms  are  not  marked. 

Smooth  patches  (Fournier)  are  not  very  perceptible  till  the  tongue  is 
dried  by  a  towel  or  some  absorbing  fabric.  They  then  appear  as  smooth,  shin- 
ing surfaces  from  which  the  epithelium  has  entirely  disappeared.  There  is 
no  sign  of  erosion.  The  lesions  are  circular  in  form,  and  are  grouped  in  circles 
or  segments  of  circles. 

This  form  of  desquamating  glossitis  is  found  in  both  the  secondary  and 
the  tertiary  period  of  syphilis.  It  at  times  precedes  the  formation  of  syphilitic 
leucoplakia. 

Scaly  patches  (syphilitic  leucoplakia)  are  rarely  seen  except  on  the  tongues 
of  habitual  smokers  and  drinkers.  They  exhibit  the  gray-white,  circular,  cir- 
cinate,  or  annular  stains  already  described,  and  occasion  no  symptoms  unless 
extensive,  when  they  may  be  associated  with  some  stiffness  of  the  tongue,  inter- 
fering with  articulation;  there  may  also  be  tingling  and  a  feeling  of  numbness. 
The  importance  of  these  lesions  lies  in  the  fact  that  they  are  prone  to  become 
fissured  and  cancerous. 

The  strictly  tertiary  lesions  of  the  tongue  may  appear  either  in  the  form 
of  a  diffuse  gummatous  infiltration  (sclerous  glossitis)  or  as  circumscribed 
gummata.  These  gummatous  lesions  develop  on  the  tongue  more  frequently 
than  in  any  other  portion  of  the  mouth.  They  are  much  more  commonly 
observed  in  men  than  in  women,  probably  because  of  the  chronic  irritation 
produced  by  the  use  of  tobacco  and  alcohol. 

Diffuse  gummatous  infiltration,  or  syphilitic  sclerous  glossitis,  is 
really  a  form  of  chronic  myositis.  It  may  be  either  superficial  or  deep,  and 
may  involve  part  of  the  tongue  or  the  whole  organ. 

The  affection  begins  as  a  slowly  progressive,  hard  swelling,  usually  involving 
but  one  side  of  the  tongue,  and  producing  marked  asymmetry.  When  both 
sides  are  enlarged  there  may  be  so  much  swelling  that  the  patient  will  not 
be  able  to  close  his  mouth.  This  condition  develops  with  comparatively  slight 
symptoms.  There  is  no  pain,  the  patient  complaining  only  of  a  feeling  of 
weight  and  stiffness,  fnaking  articulation  somewhat  labored.  After  weeks,  or 
perhaps  months,  the  swelling  gradually  subsides  coincidently  with  the  occur- 
rence of  atrophic  changes,  which  produce  even  greater  stiffening  and  induration 
than  were  present  in  the  early  stages  of  the  affection. 

Examination  of  the  surface  of  the  tongue  then  shows  irregular  lobulations, 
with  marked  alteration  of  the  mucous  membrane.  There  are  often  smooth,  red 
patches,  due  to  exfoliation  of  epithelium,  or  areas  of  greatly  thickened  epithe- 
lium, which  may  present  the  typical  white  appearance  of  syphilitic  leucoplakia. 

From  mechanical  irritation  by  the  teeth,  cracks,  erosions,  and  ulcers  are 
often  formed. 

Circumscribed  gumma,  or  gummatous  glossitis,  may  be  superficial  or 
deep — that  is,  it  may  involve  the  mucous  or  the  submucous  tissues,  or  may 
start  in  the  substance  of  the  muscles. 


764  GENITO-URINARY  SURGERY 

The  superficial  gummata  appear  as  small,  round,  hard  nodules  of  the  mu- 
cous membrane  or  submucous  connective  tissue.  They  vary  in  size  from  that 
of  a  grape-seed  to  that  of  a  cherry.  They  occasion  little  or  no  pain,  and  if 
not  treated  by  internal  medication  usually  soften  and  ulcerate,  forming  punched- 
out,  indurated,  undermined,  unhealthy  ulcers. 

When  these  gummatous  ulcers  are  multiple  and  confluent,  and  particularly 
when  they  are  phagedsenic  in  type,  they  may  destroy  the  greater  part  of  the 
tongue,  and  may  threaten  life  from  backward  extension  of  the  inflammation 
and  sudden  oedema  of  the  glottis. 

The  deep  or  muscular  gummata  begin  as  hard,  painless  tumors,  firmly  ad- 
herent to  the  surrounding  tissues.  They  are  nearly  always  placed  on  the 
dorsum  of  the  tongue.  They  occasion  little  or  no  pain,  causing  inconvenience 
only  from  the  limitation  of  motion.  They  grow  slowly,  usually  not  softening 
and  ulcerating  for  two  or  three  months.  They  vary  in  size  from  that  of  a  cherry 
to  that  of  a  lemon.  When  they  finally  ulcerate,  deep,  punched-out,  indolent, 
indurated  ulcers  are  found. 

The  ulcerating  gummata  of  the  tongue,  even  though  deep  and  confluent, 
excite  little  pain  except  on  motion,  and,  indeed,  all  the  symptoms  of  acute 
inflammation  are  absent.  On  the  healing  of  the  ulceration  there  results  a  scar, 
which  may  be  both  disabling  and  deforming. 

Diagnosis. — The  diagnosis  of  syphilitic  affections  of  the  tongue  is  made 
upon  the  general  principles  discussed  when  treating  of  syphilis  of  the  mucous 
membranes. 

It  is  particularly  on  the  tongue  that  the  lesions  of  recurrent  herpes  are  mani- 
fested, and  it  is  here  that  they  are  most  frequently  taken  for  mucous  patches 
or  other  lesions  of  active  syphilis. 

Among  other  affections  simulating  syphilis  of  the  tongue,  such  as  ichthyosis 
and  superficial  glossitis,  is  a  disease  of  infancy  variously  characterized  as 
erratic  rash,  circinated  herpes,  or  geographical  annulus  migrans.  The  tongue 
becomes  covered  with  concentric  rings  formed  by  small  red  patches.  The 
senses  of  taste  and  touch  are  normal;  sometimes,  however,  they  may  be  slightly 
hyperacute.  This  disease  may  easily  be  mistaken  for  mucous  patches  or  for 
congenital  syphilis. 

Ulcerating  gummata  of  the  tongue  may  readily  be  confounded  with  tuber- 
culous or  cancerous  lesions. 

Tuberculous  lesions  are  usually  single,  and  are  seated  at  or  near  the  tip 
or  on  the  dorsal  surface  of  the  organ.  They  begin  as  cracks  or  fissures,  at- 
tended by  swelling,  and  slowly  form  shallow,  jagged,  painful  ulcerations,  with 
non-indurated  borders,  which  are  often  surrounded  by  minute,  pale-yellow 
points  with  opaque  centres.  These  are  tuberculous  granulations  undergoing 
caseous  degeneration.  They  are  frequently  thrown  off  by  ulceration,  and  are 
never  seen  in  syphilis.  Tuberculous  glossitis  rarely  appears  as  an  isolated 
symptom  of  the  diathesis,  the  larynx,  lungs,  or  other  organs  generally  showing 
involvement.  The  tubercle  bacillus  may  be  found  on  microscopic  examina- 
tion, or  may  be  cultivated  by  inoculation  of  guinea-pigs.  The  lesion  is  slow 
in  its  course,  and  is  not  favorably  influenced  by  specific  treatment. 

The  gumma  begins  as  a  single  submucous  or  muscular  mass,  opening  after 


SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES 


765 


a  time  by  a  narrow  passage,  ulcerating  and  discharging  like  a  furuncle,  having  a 
sloughing  indurated  base. 

Carcinoma  is  generally  found  at  the  borders  of  the  tongue,  as  a  conse- 
quence of  long-standing  irritation.  It  begins  as  an  erosion  or  ulcer,  which 
subsequently  becomes  indurated,  may  show  about  its  borders  epithelial  pegs,  is 
shortly  followed  by  lymphatic  involvement,  is  steadily  progressive  and  some- 
what rapid  in  its  course,  and  is  frequently  very  painful.  The  diagnosis  may 
be  obscured,  indeed  rendered  impossible,  by  the  fact  that  carcinoma  and 
gumma  may  develop  side  by  side. 

The  points  of  difference  between  carcinoma  and  ulcerating  gumma  are 
embodied  in  the  following  table   (Fournier): 


Epithelioma. 

Period  of  Occurrence. — Chiefly  after  the 
fiftieth  year. 

History. — Often  cancerous,  and  pre- 
ceded by  lingual  psoriasis. 

Location. — Often  on  the  lateral  and 
under  surface  of  the  tongue;  uni- 
lateral. 

Number. — Single. 

Beginning. — An  irregular,  indurated, 
superficial  ulceration,  which  extends 
rapidly.  Marked  induration  follows 
ulceration. 

Appearance. — Elevated,  irregular,  evert- 
ed borders;  ulcerating  surfaces  bleed- 
ing rapidly  on  mechanical  interfer- 
ence.    No  cavity  resembling  abscess. 

Discharge.  —  Profuse,  offensive,  irri- 
tating. 

Symptoms. — Lancinating  pain  often  dart- 
ing towards  the  ear ;  great  functional 
disturbance  (deglutition,  mastication, 
speech,  etc.).     General  cachexia. 

Lymphatic  Involvement.  ■ —  Submaxillary 
lymphatic  nodes  progressively  en- 
larged and  densely  indurated. 

Therapeutic  Test. — rSpecific  treatment  use 
less  or  harmful. 

Microscopic  Examination. — Pearly  bodies. 


Gumma. 
Period  of  Occurrence. — Earlier  in  life. 

History. — Not  cancerous.  Not  preceded 
by  lingual  psoriasis. 

Location. — Always  on  the  dorsal  sur- 
face ;   may  be   bilateral. 

Number. — May   be    multiple. 

Beginning. — A  thick,  rounded  indura- 
tion, opening  like  a  furuncle,  and 
leaving  a  deep  hollow  ulcer.  Marked 
induration  precedes  ulceration. 

Appearance. — Punched-out,  sharply  de- 
fined edges;  sloughing  surface,,  not 
easily  excited  to  bleeding.  Excava- 
tion like  an  abscess-cavity. 

Discharge. — Moderate,  not  very  ofifen- 
sive. 

Symptoms. — Nearly  painless;  only  slight 
functional    disturbance.      No    cachexia. 


Lymphatic  Involvement. — None,  or  slight 
swelling  and  tenderness. 

Therapeutic      Test. —  Specific     treatment 

curative. 
Microscopic      Examination.  —  Embryonal 

cells     in     various     stages     of     granular 

degeneration. 


Syphilis  of  the  Gums. — Aside  from  the  pyorrhoea  induced  by  medica- 
tion, and  arising  from  deranged  digestion  and  secondary  lesions  in  the  mouth, 
occasionally  there  is  noted  in  tertiary  syphilis  a  distinct  pyorrhoea  alveolaris, 
signifying  syphilitic  disease  of  the  bone.  This,  unlike  the  pyorrhoea  of  medica- 
tion, is  cured  by  rapidly  pushing  the  treatment. 

Syphilis  of  the  Palate. — The  soft  palate,  uvula,  and  half-arches  usually 
show  the  diffuse  or  macular  erythema  of  the  early  secondary  specific  anginas; 
mucous  patches  are  also  frequently  found  attacking  these  structures. 

Gummata  of  the  hard  palate  usually  begin  in  the  periosteum,  and  are 
found  in  or  near  the  middle  line,  forming  elevated,  sometimes  painful,  usually 


766  GENITO-URINARY  SURGERY 

multiple,  elastic  swellings,  which  shortly  soften  and  ulcerate,  exposing  the 
bone,  resulting  in  necrosis  of  the  latter  and  in  direct  communication  between 
the  cavities  of  the  nose  and  the  mouth. 

When  these  gummata  begin  on  the  oral  surface  of  the  palate  they  usually 
can  be  detected  in  time  to  prevent  perforation. 

When,  as  is  more  commonly  the  case,  they  develop  on  the  nasal  side  of 
the  palate,  there  is  often  no  suspicion  of  trouble  till  a  dusky,  (Edematous, 
circumscribed  swelling  appears  on  the  roof  of  the  mouth,  which  in  a  very  few 
days  shows  an  opening  into  the  cavity  of  the  nose.  This  opening  represents 
the  small  end  of  a  funnel-shaped  ulcer,  which  on  examination  from  the  nasal 
side  of  the  palate  may  be  found  to  be  of  considerable  size. 

The  gummata  may  be  multiple,  and  by  confluence  may  produce  large 
openings  in  both  the  hard  and  the  soft  palate.  They  sometimes  develop 
very  rapidly,  destroying  the  uvula  and  the  greater  part  of  the  soft  palate  in 
a  few  days.  When  these  ulcerating  gummata  heal  there  may  result  great 
cicatricial  deformity,  and  perforations  which  can  be  closed  only  by  plastic 
operation. 

Gummata  of  the  soft  palate  develop  slowly,  without  pain  or  discomfort 
on  the  part  of  the  patient.  There  may  be  a  general  nodular  infiltration,  or 
but  a  single  gumma  at  one  point.  Ordinarily  there  is  a  diffuse  infiltrate,  which 
can  be  distinctly  felt  on  palpation.  If  this  primarily  involves  the  pharyngeal 
wall  of  the  palate,  the  only  appreciable  symptoms  will  be  stiffness  and  im- 
mobility, which  are  diagnostic  signs  of  considerable  value.  These  signs  can  be 
elicited  by  exposing  the  pharynx  while  the  throat  is  being  examined  and  instruct- 
ing the  patient  to  utter  some  sounds  requiring  the  assistance  of  the  soft 
palate  for  their  production.  When  immobility  is  thus  detected  and  is  found 
to  be  associated  with  nodular  induration,  the  diagnosis  of  gumma  can  be 
made  at  once.  If  the  anterior  wall  is  involved,  the  dark  red,  oedematous, 
sometimes  nodular  mucous  membrane  will  suggest  the  nature  of  the  affection. 
This  diffuse  infiltration  is  prone  to  ulcerate,  destroying  a  part  or  the  whole 
of  the  palate  and  uvula.  The  inflammatory  process  is  not  limited  to  the  soft 
palate,  often  extending  to  the  anterior  and  posterior  half-arches.  The  cicatri- 
cial processes  following  ulceration  may  produce  great  deformity.  The  soft 
palate  may  be  partly  or  totally  wanting,  or  may  be  adherent  to  the  posterior 
pharyngeal  wall,  partly  or  completely  separating  the  naso-pharynx  from  the 
pharynx;  though  not  adherent,  it  may  be  stretched  tightly  across  the  naso- 
pharynx, having  entirely  lost  its  suppleness  and  mobility. 

Circumscribed  gummata  of  the  soft  palate  may  be  single  or  multiple;  they 
are  commonly  placed  on  the  oral  surface.  They  usually  ulcerate  if  untreated, 
often  causing  perforation.  Mauriac  has  called  attention  to  the  fact  that 
gummatous  ulceration  involving  the  velum,  the  tonsil,  the  half-arches,  and  the 
lateral  wall  of  the  pharynx,  and  opening  up  the  Eustachian  tube,  often  begins 
in  the  recess  formed  by  the  juncture  of  the  anterior  and  posterior  half-arches 
and  the  upper  surface  of  the  tonsil.  This  ulceration  may  be  extensive  and  rapid, 
spreading  wide  of  the  tonsil  and  palato-pharyngeal  fold  and  even  eroding  the 
carotid  artery. 

Syphilis  of  the  Pharynx. — Gummata  of  the  pharynx  may  be  submu- 


SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES  767 

cous  or  subperiosteaL  They  usually  appear  as  one  or  more  hard,  painless 
swellings  of  the  posterior  wall.  Softening  and  ulceration  follow,  resulting  in 
deep,  punched-out,  indurated  ulcers.  When  gummatous  ulceration  involves 
both  the  soft  palate  and  the  pharynx,  adhesions  may  take  place  in  the  process 
of  healing,  which  shut  off  the  nasal  cavity  from  the  mouth;  or  by  involvement 
of  the  half-arches  and  tonsils  the  pharyngeal  communications  between  the 
mouth  and  the  larynx  may  be  greatly  narrowed. 

The  late  ulcerating  lesions  of  the  soft  palate  and  the  pharynx  are  often 
accompanied  during  their  evolution  by  pain,  disabiHty,  and  interference  with 
hearing,  and  may  be  followed  by  intractable  catarrh  of  the  naso-pharynx  inci- 
dent to  the  deformity  following  cicatrization. 

As  a  result  of  this  cicatricial  contraction  the  voice  may  be  markedly  altered; 
deglutition  may  be  difficult;  or  the  isthmus  of  the  fauces  may  be  so  narrowed 
that  there  will  be  marked  obstruction  to  the  entrance  of  air.  Such  cicatrices 
are  almost  pathognomonic  of  syphiHtic  ulceration. 

Gummata  of  the  pharynx  are  generally  associated  with  tertiary  infiltrations 
of  the  nasal  or  the  oral  mucous  membrane.  The  throat  often  presents  an  irreg- 
ularly ulcerated  appearance,  and  exceptionally  extremely  chronic,  distinct, 
punched-out,  typical  gummatous  ulcers  develop,  which,  if  untreated,  may  extend 
to  the  underlying  bone. 

The  Tonsils. — Gummata  are  very  rarely  observed  upon  the  lips  or  cheeks, 
and  are  comparatively  rare  upon  the  tonsils. 

The  ulcerating  lesion  commonly  observed  on  the  tonsil  and  often  considered 
gummatous  is  in  reality  a  vegetating  papule,  which  ulcerates,  spreads  some- 
what rapidly,  and  may  assume  a  diptheroid  or  even  a  phagedaenic  type.  The 
ulceration  is  much  more  superficial  than  is  that  of  gumma. 

Gummatous  tonsilitis  is  characterized  by  painless,  hard  enlargement,  with 
little  functional  disturbance,  except  perhaps  some  interference  with  hearing. 
The  mucous  membrane,  at  first  stretched  tightly  over  the  swelling,  becomes 
somewhat  less  tense  as  softening  takes  place,  and  finally  ruptures.  Then  re- 
sult one  or  more  punched-out  ulcers  with  indurated  borders  and  gray  slough- 
ing surfaces.  These  may  becom.e  confluent,  involving  the  anterior  half-arches, 
and  may  produce  marked  deformity  when  healing  takes  place.  Cicatricial 
contractions  resulting  from  these  gummata  may  cause  permanent  closure  of 
the  Eustachian  tube  and  interference  with  hearing. 

Subperiosteal  gummata,  resulting  in  caries  and  necrosis,  are  m.ost  frequently 
observed  on  the  hard  palate,  the  alveolar  border  of  the  upper  jaw  at  the  inser- 
tion of  the  incisor  teeth,  and  the  posterior  wall  of  the  pharynx. 

The  CEsophagus,  Stomach,  and  Intestines. — It  is  apparent  from  a 
few  reported  cases  and  from  many  autopsies  that  gummatous  ulceration  may 
occur  in  any  portion  of  the  aUmentary  canal.  It.  seems  probable,  also,  that 
the  mucous  membrane  of  this  tract  is  subject  to  specific  general  or  local  in- 
flammation during  the  secondary  period  of  the  disease.  Thus  the  symptoms 
of  catarrhal  gastritis  or  gastro-enteritis  which  are  so  frequently  associated  with 
syphilitic  fever  or  are  observed  before  or  during  the  outbreak  of  the  first 
erythema  may  be  due  to  the  direct  effect  of  syphilis  upon  the  stomach  and 
bowels.    The  chronic  gastritis  often  associated  with  specific  lesions  of  the  liver 


768  GENITO-URINARY  SURGERY 

or  spleen  may  also  represent  a  specific  infiltration,  since  it  is  favorably  influ- 
enced by  specific  treatment. 

The  (Esophagus. — ^The  superficial  lesions  of  early  syphilis  have  not  been 
recognized  in  the  oesophagus.  Deep  ulceration  extending  from  the  pharynx 
is  followed  by  stricture.  Infiltrating  gummata  developing  in  the  submucous 
connective  tissue  commonly  ulcerate,  eventually  forming  incurable  strictures. 
The  diagnosis  during  either  the  ulcerating  or  the  cicatrizing  stage  of  the  lesion 
is  dependent  absolutely  on  the  finding  of  associated  signs  of  syphilis,  in  the 
absence  of  other  etiological  factors,  and  on  the  effect  of  vigorous  constitutional 
treatment.  This,  if  pushed  in  the  ulcerating  or  early  contracting  stage,  should 
produce  rapid  improvement  in  the  symptoms  of  oesophageal  narrowing. 

The  Stomach. — ^In  addition  to  the  symptoms  of  acute  and  chronic  catarrh, 
those  of  gastric  ulcer  are  sometimes  noted.  This,  even  though  occurring  in  a 
syphilitic,  may  be  non-specific  in  nature,  or  it  may  be  due  to  the  breaking 
down  of  a  gumma.  The  symptoms  of  gastric  ulcer  of  syphilitic  origin  do  not 
differ  from  those  of  the  non-specific  ulcer.  The  diagnosis  must  be  founded  on  a 
therapeutic  test. 

The  Intestines. — Except  the  beneficial  results  of  specific  treatment,  there 
is  no  feature  of  acute  or  chronic  syphilitic  enteritis  to  distinguish  it  from  non- 
specific catarrh. 

Ulceration  of  the  small  intestine  may  be  due  to  the  breaking  down  either 
of  a  gumma  or  of  the  lymph-nodes  of  the  intestinal  wall.  According  to 
Rieder's  researches,  ulceration  of  the  bowel  is  most  frequent  in  the  upper 
portion  of  the  small  intestine.  The  ulcers  are  multiple  and  grouped,  exhibit 
the  characteristic  infiltration  of  gummatous  ulcers,  and  are  late  tertiary  mani- 
festations. They  involve  all  the  coats  of  the  bowel.  They  may  result  in 
cicatricial  stenosis. 

These  lesions  offer  no  clinical  features  peculiar  to  themselves.  Their  nature 
can  be  suspected  only  from  associated  symptoms  of  syphilis. 

Syphilis  of  the  Liver. — The  liver  may  be  affected  in  both  the  secondary 
and  the  tertiary  periods  of  syphilis.  Involvement  in  the  secondary  period  is 
rare;  tertiary  lesions,  however,  affect  the  liver  more  frequently  than  they  do  any 
other  abdominal  organ. 

Precocious  syphilis  of  the  liver  appears  in  the  first  three  months  of  the 
constitutional  disease  as  hypertrophy,  which  may  or  may  not  be  accompanied 
by  pain,  tenderness,  and  jaundice.  The  hypertrophy  is  general,  and  may 
enlarge  the  liver  to  twice  its  normal  size.  On  palpation  no  nodules  are  found, 
simply  a  general  increase  in  size.  The  prognosis  is  good,  the  enlargement  grad- 
ually diminishing  under  constitutional  treatment  till  in  from  one  to  three 
months  the  liver  is  again  normal  in  size. 

Jaundice  developing  during  the  late  secondary  period  is  rarely  due  to  syph- 
ilis. The  great  majority  of  such  cases,  when  unattended  by  hepatic  enlarge- 
ment, are  caused  by  intercurrent  affections,  such  as  a  catarrhal  condition  of 
the  bile-ducts,  and  are  neither  directly  nor  indirectly  dependent  upon  consti- 
tutional syphilis.  Calvert  has,  however,  collected  one  hundred  and  twenty- 
seven  cases  of  jaundice  occurring  as  a  manifestation  of  secondar}^  syphilis, 
and  notes  that  it  is  rapid  in   appearance,  varies  greatly  in  intensity,  recurs, 


SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES  769 

and  is  not  associated  with  grave  digestive  disturbances.  Icterus  gravis  is  most 
exceptional.  The  diagnosis  is  based  on  the  history  and  associated  symptoms 
of  syphilis  and  upon  the  rapid  improvement  under  specific  treatment. 

Tertiary  syphilis  of  the  liver  may  appear  as  interstitial  or  as  gummatous 
hepatitis.  These  tertiary  lesions  are  in  marked  contrast  to  the  secondary 
involvement  of  the  liver  from  the  fact  that  they  rarely  appear  till  late  in  the 
disease,  from  the  fourth  to  the  fortieth  year.  They  are  frequent,  they  are  per- 
sistent and  rebellious  in  treatment,  and  they  produce  permanent  alteration  in 
the  liver-substance. 

The  abuse  of  alcohol,  traumatism,  and  carelessness  in  treatment  seem  to 
be  the  factors  which  particularly  predispose  the  liver  to  tertiary  manifestations 
of  syphilis. 

Interstitial  Hepatitis  (diffuse  gummatous  infiltration). — This  runs  very 
much  the  course  of  an  ordinary  cirrhosis.  It  begins  as  a  hyperaemia,  accom- 
panied by  an  abundant  small  round-celled  infiltration  of  the  perivascular  con- 
nective tissue  of  the  liver.  This  cellular  hyperplasia  generally  appears  in  dis- 
seminated patches  of  perihepatitis^  resulting  in  adhesions  to  surrounding  organs. 
The  infiltration  of  the  substance  of  the  liver  may  be  general,  though  it  is 
commonly  found  in  patches.  The  cellular  infiltrate  becomes,  in  part  at  least, 
converted  into  connective  tissue,  which  by  its  contraction  causes  narrowing  and 
obliteration  of  ducts  and  vessels  and  atrophy  of  liver-cells.  There  is  at  first 
an  increase  in  the  size  of  the  liver,  general  or  localized,  depending  upon  whether 
hyperaemia  and  cellular  infiltrates  are  diffuse  or  appear  in  discrete  patches.  Ul- 
timately, as  the  round-celled  infiltrate  in  part  undergoes  fatty  degeneration 
and  is  absorbed,  in  part  becomes  converted  into  connective  tissue  and  contracts, 
the  enlarged  liver  becomes  smaller;  but  this  lessening  in  size  does  not  stop 
when  the  organ  has  reached  its  normal  dimensions;  the  atrophic  process 
steadily  advances;  the  surface  of  the  organ  is  lobulated,  is  marked  by  deep 
furrows,  is  creased  by  dense  fibrous  bands,  and  the  liver  is  distorted  almost 
beyond  recognition.  The  contraction  of  the  fibrous  bands  is  often  so  pro- 
nounced that  some  of  the  lobulations  thus  produced  are  almost  completely  cut 
off  from  the  rest  of  the  liver,  seeming  to  be  attached  only  by  the  fibrous  tissue 
surrounding  the  base. 

Together  with  atrophy  in  one  portion  of  the  liver  there  may  be  overgrowth 
in  another.  This  may  be  due  to  compensatory  h3rpertrophy,  the  intact  portion 
of  the  liver-substance  developing  so  that  it  may  take  the  place  of  the  portion 
destroyed. 

The  furrowing  and  lobulation  are  usually  much  more  distinctly  marked 
upon  the  convex  than  upon  the  concave  surface  of  the  organ. 

Gummatous  hepatitis  is  characterized  by  the  formation  of  gummata 
identical  in  structure  with  similar  tumors  observed  in  other  portions  of  the 
body.  These  tumors  vary  from  the  size  of  a  pea  to  that  of  a  hen's  egg;  they 
are  most  frequently  found  in  the  region  of  the  suspensory  ligament  and  along 
the  course  of  the  portal  vein,  though  they  may  appear  in  any  part  of  the 
liver;  they  may  be  grouped  or  irregularly  disseminated.  They  are  gray  or 
yellowish  in  color,  and  either  solid  throughout  or  broken  down  in  the  centre, 
according  to  the  period  of  evolution. 


770  GENITO-URINARY  SURGERY 

As  the  gummata  soften  centrally,  undergoing  fatty  and  caseous  degenera- 
tion and  becoming  absorbed,  the  peripheral  portion  of  the  neoplasm  is  con- 
verted into  fibrous  tissue,  which,  contracting,  produces  on  the  surface  of  the 
liver  deep  irregular  puckerings,  sometimes  so  marked  as  seemingly  to  divide 
the  right  lobe  of  the  liver  into  two  halves.  In  the  deeper  portion  of  the  liver 
irregular  branching  nodules  are  formed,  in  the  centre  of  which  is  sometimes 
found  a  small  amount  of  caseous  material. 

There  is  nearly  always  associated  with  these  gummata  perihepatitis,  resulting 
in  adhesions  between  the  liver  and  surrounding  structures;  this  is  particularly 
marked  on  the  upper  surface,  and  may  so  limit  the  respiratory  movements  of  the 
organ  as  to  constitute  a  sign  of  some  diagnostic  value.  Interstitial  hepatitis  and 
amyloid  degeneration  of  the  liver,  spleen,  kidneys,  and  intestinal  mucous  mem- 
brane are  also  frequently  noted  in  connection  with  old  gummata. 

The  gummata  of  the  liver  do  not  ulcerate;  they  develop  slowly,  and  may 
not  reach  their  ultimate  stage  of  cicatrization  for  several  years. 

Symptoms, — The  symptoms  of  syphilitic  interstitial  hepatitis  are  rarely  well 
marked.  In  the  early  stage  there  is  a  feeling  of  weight  in  the  hepatic  region, 
followed,  often  after  a  long  period,  by  hypertrophy,  slow  in  development,  and 
unattended  by  signs  of  inflammation.  Sometimes  the  hypertrophy  is  general, 
the  lower  border  of  the  liver  extending  three  finger-breadths  below  the  margin 
of  the  ribs,  and  revealing  to  palpation  a  smooth,  regular  surface.  Often  the 
hypertrophy  is  not  so  marked,  palpation  showing  surface  irregularities  or  eleva- 
tions. It  is  dependent  upon  compression  of  the  portal  vein  from  perivascular 
hyperplasia.  • 

Functional  disturbances  are  limited  to  general  dyspeptic  symptoms,  even 
these  not  being  noted  at  times.  As  the  disease  progresses  and  atrophy  sets  in, 
the  only  sign  which  may  be  considered  characteristic  is  the  deformity  incident 
to  cicatricial  contraction.  A  nodular  surface,  an  irregular  fissured  border, 
gradually  becoming  less  perceptible  to  palpation  in  one  portion  while  overgrowth 
is  observed  in  another  region,  and  adhesions  to  surrounding  structures,  are  all 
signs  which  would  suggest  syphilis. 

Icterus  is  comparatively  rare;  hsematemesis,  diarrhoea,  digestive  troubles, 
and  swelling  of  the  legs  develop  as  in  the  case  of  cirrhosis  from  causes  other 
than  syphilis. 

Ascites  is  frequently  noted;  fluid  accumulates  slowly  in  the  first  place,  but 
on  tapping  reaccumulates  rapidly.  Often  there  are  no  premonitory  symptoms; 
a  painless  ascites  gradually  develops,  associated  with  jaundice,  discolored  urine, 
swelling  of  the  ankles,  varicose  veins,  and  possibly  albuminuria. 

Gummatous  hepatitis  in  the  early  stages  may  give  rise  to  no  symptoms,  and 
may  not  seriously  interfere  with  the  functions  of  the  liver.  As  the  disease 
progresses,  the  accompanying  hepatitis,  perihepatitis,  and  amyloid  degeneration 
cause  most  of  the  suffering  and  interference  with  general  health.  The  liver 
is  usually  of  normal  size,  presenting  to  the  examining  finger  a  nodular  irregular 
border.  Gastro-intestinal  symptoms  are  marked,  pain  may  be  severe  and  con- 
stant, and,  when  the  atrophic  process  is  well  developed,  bleeding  from  the  stomach 
or  from  the  oesophagus  may  become  a  serious  complication. 

Enlargement  of  the  spleen  and  albuminuria  are  commonly  associated  with 


SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES  771 

specific  hepatitis.    As  a  consequence  of  this  involvement  of  the  liver,  spleen,  and 
kidneys,  pronounced  cachexia  ensues. 

Prognosis. — The  prognosis  of  tertiary  syphilis  of  the  liver  is,  if  the  affection 
is  taken  in  its  earlier  stages,  fairly  good.  The  gummatous  form  yields  more 
readily  to  specific  treatment  than  the  diffuse  or  cirrhotic  form.  When  extensive 
fibroid  changes  have  taken  place,  and  particularly  when  there  are  associated 
lesions  of  the  kidneys  and  spleen  and  marked  cachexia,  the  prognosis  must  be 
exceedingly  guarded. 

Diagnosis. — The  diagnosis  of  liver  sj^hihs  is  founded  upon  alterations 
in  the  size  and  shape  of  the  liver,  associated  with  much  milder  symptoms  than 
are  attendant  on  such  alterations  when  they  are  due  to  other  causes.  There  is 
usually  a  history  of  syphilis;  or  a  positive  Wassermann,  or  both. 

Gummatous  hepatitis  may  simulate  cancer.  The  latter  affection,  however, 
occurs  in  those  past  middle  age,  and  is  rarely  primary.  It  is  not  so  liable  to 
contract  adhesions  as  are  gummata:  hence  its  nodulations  are  more  readily  felt; 
it  produces  early  and  profound  cachexia;  it  grows  much  more  rapidly  than 
gumma,  and  associated  enlargement  of  the  spleen  is  rare. 

Treatment. — All  forms  of  hepatic  syphilis  occurring  in  the  early  secondary 
period  should  be  treated  by  arsenic  and  mercury. 

In  the  form  generally  observed — that  is,  as  a  late  tertiary  manifestation — 
in  addition  to  the  specific  drugs  potassium  iodide  should  be  administered  in 
doses  as  large  as  the  patient  can  tolerate.  The  dose  required  is  sometimes  as 
high  as  two  or  three  drachms  daily. 

Tonics,  mild  stimulation,  bathing,  exercise,  diet,  and  general  hygiene  must 
receive  careful  consideration. 

Amyloid  degeneration  is  so  frequently  associated  with  syphilis  that  the 
latter  must  be  recognized  as  an  etiological  factor  in  its  production.  As  when 
it  complicates  tuberculosis,  it  may  follow  extensive  suppurative  processes.  It 
is  also  found,  however,  in  conjunction  with  the  sclerotic  or  the  gummatous  form 
of  hepatitis,  and  is  commonly  complicated  by  a  similar  affection  of  the  spleen, 
the  kidneys,  and  often  the  intestinal  mucous  membrane.  The  liver  rarely 
reaches  the  enormous  size  sometimes  observed  in  amyloid  degeneration  from 
other  causes. 

In  itself  amyloid  degeneration  does  not  cause  ascites,  and  gives  rise  to  no 
functional  disturbances  until  it  is  far  advanced.  Ultimately  digestive  dis- 
turbances become  pronounced,  and,  as  the  result  of  similar  degeneration  of  the 
intestinal  mucosa,  multiple  ulcers  develop,  causing  blood-stained  stools.  There 
is  usually  oedema,  and,  if  the  kidneys  are  also  involved,  albuminuria.  Cachexia 
is  well  marked. 

The  diagnosis  is  based  on  finding  an  enlarged,  smooth,  firm,  non-sensitive 
liver,  together  with  other  signs  of  late  syphilis.  In  amyloid  degeneration  with 
gummatous  or  sclerotic  processes  the  liver  may  be  ridged,  notched,  or  otherwise 
deformed. 

The  prognosis  is  extremely  grave.  The  treatment  is  that  appropriate  to 
late  syphilis,  combined  with  tonics,  stimulants,  carefully  regulated  diet,  and 
minute  attention  to  general  hygiene. 

Syphilis  of  the  Pancreas.- — Specific  disease  of  this  organ  may  take  the 
form  of  interstitial  pancreatitis  or  of  gummatous  involvement. 


772  GENITO-URINARY  SURGERY 

These  lesions  are  rare.  Their  presence  is  not  indicated  by  characteristic 
symptoms  during  life.  There  is  usually  marked  involvement  of  other  abdominal 
organs. 

The  Rectum  and  Anus. — About  the  anal  aperture,  especially  in  women, 
mucous  patches  frequently  form.  These,  from  maceration  and  from  the  irrita- 
tion incident  to  defecation,  are  prone  to  ulcerate,  forming  rhagades  and  fissures, 
which,  by  extending  in  depth,  may  involve  the  tissues  of  the  ischiorectal  space, 
forming  deep  ulcers  or  resulting  in  fistulae.  It  is  important  to  bear  in  mind 
that  such  lesions  may  occur  in  the  secondary  stage  of  syphilis. 

Gummata  may  develop  on  or  beneath  the  mucous  membrane  of  the  anus 
and  rectum,  or  in  the  surrounding  tissue  of  the  ischiorectal  fossa.  Not  infre- 
quently they  assume  the  form  of  a  diffuse  infiltration,  producing  rigidity  of  the 
walls  of  the  bowel,  the  mucous  membrane  remaining  quite  healthy.  This  may 
be  followed,  if  untreated,  by  ulceration  or  interstitial  absorption,  in  either  case 
resulting  in  stricture. 

Gummatous  ulceration  of  the  mucous  membrane  usually  begins  about  the 
internal  sphincter,  appearing  first  as  one  or  many  small  nodules,  which  soften 
and  break  down,  exhibiting  dark  gelatinous  cores.  They  finally  destroy  the 
overlying  mucous  membrane,  forming  ulcers,  which  become  confluent,  extend 
in  area  and  depth,  and  are  generally  accompanied  by  inflammatory  infiltration 
of  the  muscular  coat  of  the  gut,  including  the  sphincter,  thus  producing  a 
narrowing  and  rigidity  distinctly  perceptible  to  the  examining  finger. 

The  ulceration  frequently  extends  upward,  other  gummata  forming  and  ulcer- 
ating. From  the  surface  and  border  of  these  ulcers  there  may  be  an  exuberant 
growth  of  granulations,  producing  fungous  masses,  which  may  simulate  those  of 
malignant  disease. 

Healing  is  accompanied  by  the  formation  of  scar-tissue,  which  in  its  subse- 
quent contraction  often  produces  tight  strictures. 

The  perirectal  gummata  form  tumors  which  may  reach  considerable  size 
before  involving  and  breaking  through  the  mucous  membrane.  As  a  result  of 
the  entrance  of  the  bowel  contents  into  the  cavities  of  these  gummata,  ischio- 
rectal abscesses  are  formed,  terminating  in  fistulae.  These  fistulae  may  be  vesical 
or  vaginal,  are  often  multiple,  and  in  some  cases  riddle  the  entire  perineum, 
even  opening  on  the  surface  of  the  thighs. 

The  strictures  resulting  from  cicatrization  of  recto-anal  ulceration  are  much 
more  frequent  in  women  than  in  men.  They  are  generally  found  involving  the 
lowest  portion  of  the  rectum,  and  are  often  associated  with  vegetating  ulcers. 

Symptoms. — The  acute  or  chronic  proctitis  often  accompanying  ulceration 
and  gummata  of  the  rectum  occasions  a  muco-purulent  discharge,  a  feeling  of 
fulness  in  the  rectum,  and  usually  moderate  tenesmus.  When  the  ulcers  become 
fissured  and  deep,  burning  pain,  tenesmus,  and  blood-stained  purulent  discharge 
are  prominent  symptoms.  The  passage  of  faeces  occasions  some  suffering,  and 
is  usually  followed  by  bleeding.  When  stricture-formation  is  fairly  well  ad- 
vanced there  will  be  constipation  alternating  with  diarrhoea  and  the  passage  of 
ribbon-shaped  or  broken  stools. 

The  prognosis  must  be  guarded.  Even  if  active  specific  treatment  cures 
the  palpable  lesions,  there  sometimes  follows  faecal  incontinence,  from  atrophy 


SYPHILITIC  LESIONS  OF  THE  MUCOUS  MEMBRANES  771 

of  the  sphincter  consequent  on  interstitial  myositis.     Ulcers  about  the  rectum 
are  always  extremely  slow  to  heal. 

Diagnosis. — The  lesions  of  syphilis  must  be  distinguished  from  those  ot 
tuberculosis  and  cancer. 

The  tuberculous  ulcer  is  found  in  persons  exhibiting  other  undoubted  lesions 
of  tuberculosis. 

Cancer  closely  simulates  infiltrating  and  ulcerating  gummata.  It  is  more 
prone  early  to  contract  tight  adhesions  to  neighboring  parts,  and  is  usually 
placed  higher  up  the  bowel  than  gumma.  Excision  and  examination  of  a  portion 
of  the  growth  would  establish  its  pathology. 

Treatment. — In  addition  to  general  specific  medication,  the  ulcerating  sur- 
faces must  be  treated.  WTien  these  are  slight  and  superficial,  regulation  of  the 
bowels  and  cleansing  injections  repeated  night  and  morning  may  be  sufficient. 
Deep  ulcers  may  require  stretching  of  the  sphincter  followed  by  prolonged  rest 
in  bed,  with  daily  topical  applications  suited  to  the  condition  of  the  granulating 
surface.    Strictures  can  be  benefited  only  by  dilatation  or  operation. 


CHAPTER  XXXVII 
SYPHILIS  OF  THE  NERVOUS  SYSTEM 

CEREBRAL  SYPHILIS 

There  is  no  nervous  symptom  caused  by  syphilis  which  ma>'  not  be  paralleled 
by  a  symptom  found  in  a  neuropathy  from  another  cause;  in  other  words, 
there  are  no  symptoms  pathognomonic  of  the  disease.  Caries  of  the  bones 
of  the  skull,  indirectly  implicating  the  brain,  produces  the  same  symptoms 
whether  the  caries  be  tuberculous,  traumatic,  or  syphilitic,  and  pachymeningitis, 
endarteritis,  and  cerebral  growths  cause  similar  symptoms  regardless  of  their 
etiology,  but  dependent  rather  on  their  rate  of  progress. 

Etiology. — A  nervous  temperament  seems  to  predispose  to  the  development 
of  brain-lesions,  though  from  this  it  must  not  be  understood  that  brain-workers 
are  more  prone  to  suffer  from  this  form  of  the  disease  than  are  others.  The 
conditions  which  certainly  predispose  to  the  development  of  brain-symptoms 
during  the  course  of  syphilis  are  absence  of  a  sufficiently  long  and  thorough 
course  of  specific  treatment  during  the  secondary  and  the  early  tertiary  period 
of  the  disease,  alcoholism,  or  hereditary  neurosis.  The  rheumatic  diathesis, 
traumatism,  prolonged  worry  or  anxiety,  and  exposure  to  cold  or  heat  are  also 
held  to  favor  the  same  result. 

In  the  large  majority  of  cases  in  which  syphilis  attacks  the  nervous  system, 
it  does  so  in  the  absence  of  any  obviously  sufficient  cause,  and  "  simply,"  as 
Mauriac  says,  "because,  forsooth,  it  pleases  it  to  do  so." 

Mauriac  and  Broadbent,  among  others,  have  observed  that  in  cases  of  cerebral 
syphilis  the  primary  lesion  and  the  early  manifestations  are  more  than  likely 
to  have  been  quite  insignificant;  no  positive  conclusion,  however,  can  be  based 
upon  this  observation,  because  no  one  would  maintain  the  truth  of  its  converse — 
viz.,  that  because  the  secondary  lesions  or  manifestations  were  severe,  no  in- 
vasion of  the  nervous  system  would  follow.  The  probable  reason  why  syphilis 
attacks  the  nervous  system  after  a  light  secondary  stage  is  that,  on  account  of 
its  mildness,  a  sufficiently  vigorous  and  prolonged  treatment  was  not  enforced. 
Violent  nervous  disturbances  occurring  at  the  time  of  the  secondary  eruption 
and  disappearing  with  it  do  not  necessarily  indicate  a  future  determination  of 
the  disease  to  the  brain  or  the  spinal  cord;  but  if  these  disturbances  increase 
after  the  disappearance  of  the  cutaneous  eruption,  or  if  after  disappearing  they 
reappear,  the  prognosis  as  regards  cerebropathies  must  be  guarded. 

Time  of  Appearance. — Neural  syphilomata  are  the  most  precocious  of  all 
the  tertiary  manifestations;  the  nervous  centres  may  be  attacked  at  any  period 
of  the  disease  after  the  beginning  of  the  secondary  stage.  The  usual  time  for 
their  appearance  is  in  the  first  three  years  after  infection,  but  they  may  manifest 
themselves  even  as  late  as  eighteen  years  after  the  infecting  chancre.  Later 
than  this  they  are  of  greater  rarity.  Tabes  and  general  paralysis  are  commonly 
much  later  in  making  their  appearance  than  are  the  other  neural  lesions  of 
syphilis,  the  average  time  being  about  ten  years  after  the  chancre. 
774 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  775 

Pathology. — Brain-lesions  of  syphilis  may  appear  as  areas  of  sclerosis  or  of 
softening  and  atrophy,  or  gummata  may  develop.  In  either  case  the  pathology 
is  the  same.  There  are  cellular  proliferation  and  formation  of  vascularized 
granulation-tissue,  usually  diffuse  in  the  case  of  the  central  nervous  system  and 
its  membranes,  and  ultimately  resulting  in  atrophy  and  sclerosis.  Exceptionally 
cellular  proliferation  is  circumscribed  and  extensive,  forming  gumma.  Asso- 
ciated with  these  changes,  or  developing  independently  of  them,  syphilitic 
arteritis  is  a  prime  factor  in  the  causation  of  brain-  and  cord-lesions. 

Gummata  are  formed  with  far  less  frequency  in  the  cerebral  tissue  proper 
than  in  the  bones  of  the  skull,  or  in  the  meninges  or  the  subarachnoid  space. 
When  they  form,  however,  they  assume  the  same  general  appearance  as  else- 
where. They  are  seldom  smaller  than  a  pea  or  larger  than  an  egg,  are  very 
consistent,  with  a  caseous  dry  core,  and  are  surrounded  by  highly  vascular 
cerebral  tissue  containing  numerous  embryonal  connective-tissue  cells. 

Gummata  are  commonly  found  in  groups  of  three  or  four;  these  may  be 
single  or  multiple.  Although  they  may  be  found  throughout  the  brain,  they 
usually  grow  from  the  dura  mater  or  the  arachnoid  membrane  at  the  base  of  the 
cerebral  hemispheres  near  the  pituitary  body,  or  on  the  convexity  about  the 
frontal  convolutions. 

It  is  at  times  extremely  difficult  to  distinguish  a  large  tubercle  of  the  brain 
from  gumm.a.  The  symptoms  will  be  the  same.  An  autopsy  shows  the  tubercle 
as  a  somewhat  regular  and  sharply  defined  tumor,  with  no  extensions  into  the 
surrounding  tissue,  frequently  exhibiting  miliary  tubercles  about  the  periphery, 
and  at  times  having  undergone  almost  complete  caseous  degeneration.  These 
are  characteristics  never  observed  in  gummata.  Tubercle  is  found  far  more 
frequently  in  the  young,  and  is  usually  associated  with  deposits  elsewhere  in 
the  body.  Nowhere  else,  however,  have  these  two  lesions  such  similarity  as 
in  the  brain. 

Gumma-formation  in  the  brain  is  not  a  rapid  process;  it  increases  slowly 
up  to  a  certain  point,  and  then  remains  a  long  time  stationary  unless  by  its 
size  the  gumma  occludes  blood-vessels  and  thereupon  sets  up  a  passive  hy- 
peraemia  or  ischaemia  with  consequent  softening,  which  is  the  natural  tendency 
of  all  such  neoplasms.  Under  antisyphilitic  treatment,  however,  gummata  may 
be  apparently  absorbed,  or  at  least  checked,  and  then,  not  infrequently,  a  post- 
mortem discloses  on  the  surface  of  the  brain  characteristic  cicatrices  or  depres- 
sions, which  are  the  remains  of  the  preexisting  gummata,  of  which  the  patient 
had  been  apparent^  cured  for  many  years. 

Intracranial  syphilitic  processes  never  involve  the  entire  tissue  wherein  they 
are  situated,  but  are  apt  to  develop  from  several  foci  situated  on  any  of  the 
intracranial  tissues.  They  seldom  attain  a  large  size,  and  even  the  pseudo- 
membranous patches  of  the  dura  mater,  or  gummatous  pachymeningitis,  never 
cover  completely  the  surfaces  of  the  membrane  over  the  hemispheres,  wherein 
they  differ  from  the  ordinary  congestive  and  inflammatory  processes. 

Syphilitic  processes  in  general  are  far  more  frequently  found  on  the  surface 
of  the  brain  and  in  the  meninges  than  deep  in  the  cerebral  substance.  Their 
most  frequent  seat  is  on  the  frontal  portions  and  on  the  base  of  the  brain  in 
the  sphenoidal  region. 


776  GENITO-URINARY  SURGERY 

In  addition  to  the  gummatous  and  sclerotic  lesions,  which  are  the  direct 
product  of  syphilis,  there  are  lesions  dependent  on  inflammatory  or  ischsemic 
processes  — the  sequelae  of  syphilitic  endarteritis.  This  endarteritis  brings  about 
a  narrowing  of  the  calibre  of  the  vessels,  producing  a  lessened  blood-supply  and 
consequent  interference  with  function.  As  this  narrowing  increases,  thrombosis 
may  occur,  with  complete  obliteration,  in  consequence  of  which,  if  the  vessel 
affected  is  a  terminal  artery,  the  portion  of  the  brain  supplied  by  this  vessel 
degenerates.  When  the  basilar  arteries  are  involved,  the  free  collateral  circu- 
lation prevents  any  symptom,  even  though  the  process  has  advanced  to  throm- 
bosis. From  this  clot,  however,  an  emblous  may  be  loosened,  which  will  produce 
the  same  symptoms  as  cerebral  embolism  occurring  in  the  course  of  any  other 
disease.  The  degeneration  of  the  arteries,  whether  caused  by  syphilis  direct  or 
by  the  proximity  of  syphilitic  lesions,  is  perhaps  the  most  important  factor  in 
the  cerebropathies  of  syphilis,  particularly  in  regard  to  softening  and  hemor- 
rhages. 

When  syphilis  attacks  the  bones  of  the  skull  there  may  be  cerebral  symp- 
toms, caused  either  by  an  actual  infection  of  the  brain  or  by  a  mechanical  com- 
pression arising  from  a  gummatous  formation  or  by  the  presence  of  pus  between 
the  bones  of  the  skull  and  the  dura  mater.  It  is  rare  that  the  brain-substance 
at  the  point  of  the  osseous  lesion  is  not  affected. 

In  the  patches  of  chronic  syphilitic  pachymeningitis  there  is  little  to  char- 
acterize as  specific;  in  all  respects  they  resemble  patches  of  pachymeningitis 
produced  by  any  other  cause.  When  situated  on  the  upper  surface  of  the 
membrane  these  sclerotic  patches  can  involve  large  areas  without  giving  rise 
to  appreciable  symptoms,  but  when  situated  in  the  membrane  surrounding  the 
canals  of  exit  of  the  nerves  they  become  highly  dangerous. 

Gummata  of  the  dura  mater  may  occur  on  either  surface  of  that  membrane, 
and  are  round,  of  firm  consistence,  sometimes  a  little  soft,  almost  never  liquid. 
One  or  more  may  be  present,  from  the  size  of  a  millet-seed  to  that  of  an 
egg;  they  are  grayish  in  color,  with  a  firm  centre.  The  adjoining  nerves  are 
atrophied,  and  the  arteries  may  be  not  only  obstructed  by  compression  but 
invaded  by  the  gummatous  material,  or  even  obliterated.  Obliteration  of  the 
carotid,  middle  meningeal,  and  basilar  arteries  has  been  noted.  In  a  case  of 
gumma  of  the  tentorium  cerebelli  all  the  sinuses  bordering  on  the  torcular  Hero - 
phili  were  obliterated  (Dowes). 

Syphilomata  of  the  arachnoid  alone  are  rare,  and  appear  as  opalescent  spots 
more  or  less  thickened.  They  are  either  diffuse  or  grouped  in  compact  masses 
in  the  centres  of  which  are  gray  degenerations.  True  gummata  are  very  rarely 
found. 

The  pia  mater  is  the  cranial  tissue  wherein  the  development  of  syphilitic 
meningitis  is  by  far  the  most  frequent. 

From  this  membrane  the  greater  part  of  the  sclerotic  and  gummatous  changes 
start,  subsequently  invading  the  encephalon.  The  lesions  are  more  often  of  a 
fibro-cellular  character  than  gummatous,  and  assume  the  form  of  plates  or 
bands,  following  the  course  of  vessels,  most  frequently  along  the  edge  of  the 
fissure  of  Sylvius.  They  consist  merely  of  opalescent  patches,  with  a  slight 
thickening  of  the  membranes.     Their  tendency  to  extend  along  the  vessels  or 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  ^TT 

nerves  often  produces  symptoms  of  circumscribed  ischaemia  and  cerebral  mal- 
nutrition, as  well  as  neuralgias  and  paralyses  of  certain  nerves.  The  motor 
nerves  of  the  eye  and  the  fifth  pair  are  most  liable  to  be  thus  affected. 

The  postmortem  appearance  of  these  lesions  shows  a  close  union  of  the 
membranes  of  the  brain,  with  perhaps  a  slight  adhesion  to  the  cerebral  cortex. 
True  gummata  in  the  pia  mater  are  not  quite  so  common  as  in  the  dura;  they 
may  attain  large  size.  They  are  most  frequently  found  in  the  frontal  regions 
and  at  the  base  of  the  brain  near  the  sella  turcica.  Small  gummatous  nodules 
also  form  along  the  arteries,  and  impinge  not  only  on  the  brain  but  on  the 
arteries  themselves,  at  first  obstructing  their  lumina  and  afterwards  obliterating 
them,  thus  producing  ischaemia  of  the  brain. 

The  arteries  of  the  brain  are  always  more  or  less  implicated.  When  they  are 
themselves  the  seats  of  syphilitic  degeneration  they  influence  the  nervous  system 
directly  by  means  of  aneurismal  dilatation  or  by  hemorrhages  which  press  upon 
the  brain-substance.  Indirectly,  syphilis  of  the  arteries  can  affect  the  brain  by 
narrowing  the  lumen  of  the  vessels  and  by  destroying  their  elasticity,  thus  cutting 
off  the  blood-supply;  all  the  symptoms  of  cerebral  ischaemia  thereupon  follow. 
A  thorough  postmortem  microscopical  examination  is  sometimes  required  to 
reveal  the  numerous  military  aneurisms  along  the  smaller  arteries  and  capillaries 
or  the  obliteration  of  these  vessels. 

Syphilis,  then,  may  attack  the  brain  in  the  form  of : 

1.  Diffuse  gummatous  infiltration  of  the  meninges,  with  extension  to  the 
brain-substance. 

2.  Gummata,  or  circumscribed  tumors. 

3.  Endarteritis,  with  its  concomitant  brain-lesions. 
Symptomatology.^ — An  examination  of  the  symptoms  of  syphilis  of  the 

cerebrum  and  of  its  envelopes  must  include  all  known  symptoms.  But,  while 
there  exists  no  one  pathognomonic  sign  to  serve  as  a  guide,  there  are,  never- 
theless, groups  of  symptoms,  subjective  or  objective,  which  are  fairly  distinctive. 

In  general,  syphilitic  neuroses  are  characterized  by  multiplicity  and  incoordi- 
nation of  symptoms  of  either  gradual  or  rapid  development. 

Except  headache,  disturbances  of  sensation,  whether  neuralgias  or  anaesthe- 
sias, are  not  commonly  due  to  syphilis  when  they  predominate  over  the  other 
symptoms.  On  the  other  hand,  disturbances  of  motility  are  frequent.  Cerebral 
syphilis  will  inevitably,  sooner  or  later,  if  left  to  itself,  develop  a  paralysis  or 
paresis.  The  neurosis  may  be  at  first  revealed  by  epileptiform  convulsions,  but 
eventually  paresis  sets  in,  together  with  symptoms  of  cerebral  degeneration,  rapid 
loss  of  memory,  and  weakened  cerebration. 

As  a  prodromal  symptom  headache  is  chiefly  characteristic.  This  varies 
greatly  in  intensity.  It  is  worse  at  night,  and  is  usually  constant,  is  deep- 
seated  and  extremely  harassing,  and  is  accompanied  by  a  certain  failure  in 
mental  power,  a  lack  of  ability  to  concentrate  the  attention,  and  a  condition 
of  nervousness  characterized  by  foreboding  and  a  marked  excitement  from 
trifling  causes.  When  there  is  meningitis  of  the  convexity,  tenderness  to  pressure 
or  percussion  may  be  noted.  There  are  often  vertigo,  insomnia,  and  profound 
mental  depression. 

When  the  syphilitic  process  is  circumscribed,  as  in  the  case  of  a  gumma 


778  GEXITO-URIXARY  SURGERY 

or  of  an  aneurism  due  lo  svphilitic  arteritis,  the  pain  is  restricted  to  a  limited 
area,  and  is  described  as  like  that  of  a  nail  being  driven  into  the  head.  When 
patches  of  sclerosis  are  extensive,  the  cephalalgia  may  cover  all  one  side  of 
the  head. 

Aside  from  s^-philitic  affections  of  the  brain  and  its  meninges,  the  pain  may 
be  due  to  lesions  of  the  cranial  bones,  or  ma}^  develop  as  bone  neuralgia. 

Sj'philitic  neuralgias  are  characterized  by  pain  located  in  the  trunk  or 
branches  of  distribution  of  a  given  nerve,  and  are  aggravated  by  pressure  along 
the  course  of  this  ner\'e,  particularly  at  its  point  of  emergence  from  the  bone. 
This  pain  most  frequently  attacks  the  fifth  pair,  and  has  for  its  type  supraorbital 
neuralgia.  It  is  observed  during  the  early  stage  of  the  secondary  period — that 
is,  in  the  first  six  or  eight  months  of  the  disease,  ^^^aen  it  occurs  during  the 
tertiary  period  it  is  nearly  alwa3^s  due  to  a  distinct  infiltration;  sometimes  it  is 
caused  by  the  pressure  of  a  gumma  or  bony  outgrowth.  These  specific  neu- 
ralgias exhibit  the  symptoms  characteristic  of  neuritis.  They  have,  however, 
a  tendency  to  become  worse  at  night,  and  3'ield  promptly  to  specific  treatment. 
The  therapeutic  test  is  the  only  means  of  making  a  positive  diagnosis. 

Pain  due  to  bone-involvement  may  occur  in  the  early  stages,  during  the 
height  of  the  disease,  or  at  a  late  tertiary  period.  It  is  most  frequent  in  the 
tertian,'  period,  and  is  then  readily  recognized,  since  the  lesions  are  gross,  pro- 
ducing considerable  deformity. 

Secondarj^  lesions  are  slight,  circumscribed,  and  readily  overlooked,  especially 
when  they  develop  beneath  the  hairy  scalp.  They  are  characterized  by  cir- 
cumscribed areas  of  h}'peraesthesia  ■vAithout  appreciable  infiltration  and  are 
common  in  women. 

The  periostitides  produce  slight  circumscribed  swelling  of  the  bone,  particu- 
larly in  the  parietal,  temporal,  and  frontal  regions.  The  involved  areas  are 
small — about  the  size  of  a  ten-cent  piece,  sometimes  as  large  as  a  fifty-cent 
piece — ver\'  slightly  raised,  sometimes  obscurely  fluctuating.  There  may  be 
true  bone  proliferation.  They  are  painful  and  extremely  sensitive.  This 
excessive  sensibility  is  a  characteristic  sign. 

The  ostealgias  are  characterized  solely  by  pain  and  tenderness.  There  is 
neither  swelling  nor  appreciable  alteration  of  any  kind.  The  pathological  basis 
of  this  symptom  is  unkno\Mi.  The  pain  is  sometimes  agonizing,  and  often 
radiates  over  a  large  surface. 

Headaches  due  to  sj^hilitic  affections  of  the  brain  or  its  envelopes  are  more 
diffuse  and  more  deeply  placed  than  those  dependent  upon  bony  lesions  or 
upon  neuralgias. 

Secondary  syphilitic  headache,  which  develops  during  the  early  periods  of 
this  stage  of  the  disease,  is  common,  especially  in  women ;  untreated  it  is  usually 
severe  and  prolonged.  It  is  severe  in  the  regions  of  the  forehead,  the  temples, 
and  the  occiput.  The  pain  may  be  described  as  a  feeling  of  weight  in  the 
head,  or  a  beating,  or  a  sense  of  pressure;  sometimes  it  is  lancinating  or  tearing, 
as  if  the  cranium  were  about  to  burst.  The  pain  varies  greatly  in  intensity; 
h  may  be  slight,  bearable,  not  interfering  ^A^th  the  pursuits  of  life;  or  as  severe 
as  an  ordinar>'  migraine,  preventing  work,  particularly  that  requiring  much 
thought,  and  disturbing  sleep :  or  agonizing  and  absolutely  unbearable. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  779 

Associated  with  the  headache  there  are  usually  diminution  of  appetite,  dis- 
ordered digestion,  general  malaise,  nervous  erethism,  great  excitability,  and  some- 
times disturbance  of  vision,  with  vertigo.  The  patient  becomes  morose,  melan- 
cholic, stupid,  and  forgetful. 

These  headaches  may  assume  the  intermittent  type  or  the  continuous  type 
with  exacerbations.  The  intermittent  type  is  most  frequent,  especially  in  the 
slight  forms  and  those  of  medium  severity.  The  pain  usually  comes  on  at  about 
five  or  six  o'clock  in  the  evening  and  disappears  during  the  night,  often  recurring 
at  the  same  hour  and  in  the  same  form  day  after  day  and  following  the  same 
course. 

The  continuous  type  with  exacerbations  is  less  frequent.  In  these  cases  the 
headache  never  disappears  entirely;  but  here  again  the  exacerbation  is  observed 
in  the  evening  or  during  the  night. 

In  some  cases  these  secondary  headaches  disappear  in  a  few  days  or  one 
or  two  weeks.    Usually  they  persist  for  several  weeks,  or  even  for  several  months. 

Diagnosis. — The  diagnosis  is  founded  on  the  nocturnal  exacerbations  and 
the  prompt,  characteristic,  and  extraordinarily  curative  effect  of  specific  treat- 
ment. Xight  exacerbations  of  cephalalgia  are  not  confined  to  syphilis.  From 
the  symptoms  alone  these  headaches  cannot  be  distinguished  from  those  of 
anaemia,  of  hysteria,  or  of  rheumatism.  Fortunately,  syphilitic  headache  is 
commonly  associated  with  other  incontestable  signs  of  disease  or  with  a  history 
which  is  suggestive.  Usually  there  are  syphilides  or  alopecia  and  articular 
pains.  In  the  rare  cases  where  both  history  and  concomitant  symptoms  of 
syphilis  are  wanting,  an  elimination  of  other  causes  of  cephalalgia  would  suggest 
syphilis  and  consequently  specific  treatment.  Thus,  neuralgic  cephalalgia  would 
be  distinguished  by  pain  referred  to  certain  points  along  the  course  of  nerves; 
migraine,  by  comparatively  long  periods  of  remission:  rheumatic  cephalalgia, 
by  superficial,  muscular  pain,  increased  on  contraction  of  muscles,  and  relieved 
by  heat;  anaemia  cephalalgia,  by  the  facts  that  it  lessens  during  the  evening, 
that  it  is  made  better  by  eating,  and  that  it  is  accompanied  by  other  symptoms 
of  lessened  haemoglobin;  neurasthenic  cephalalgia,  by  its  less  severe  pain,  its 
partly  diurnal  character,  and  its  long  continuance. 

Treatment. — The  specific  treatment  of  secondary  cephalalgia  is  attended 
by  prompt  results.  Full  doses  of  potassium  iodide  should  be  a  part  of  the 
treatment. 

Prodromal  Cephalalgia  of  Tertiary  Lesions. — The  most  important 
variety  of  specific  migraine  is  that  preceding  the  grosser  symptoms  of  cerebral 
syphilis.  In  certainly  two-thirds  of  all  cases  of  hemiplegia,  amnesia,  aphasia, 
epilepsy,  coma,  pseudo-paralysis,  etc.,  dependent  upon  sj^hilis,  there  is  this 
prodromal  headache.  A  large  percentage  of  these  cases  could  have  been  saved 
from  these  grave  accidents  by  vigorous  treatment  instituted  during  the  pro- 
dromal period. 

This  headache  differs  from  other  cephalalgias,  as,  for  instance,  those  due  to 
neuralgia  or  to  epicranial  rheumatism,  in  the  fact  that  it  is  felt  to  be  deep 
within  the  head.  The  character  of  the  pain  varies:  1,  there  may  be  simply 
a  sense  of  weis:ht  and  hebetude;  2.  there  may  be  a  constrictive  pain,  as  though 
the  head  were  screwed  in  a  vise;  3,  the  sensation  may  resemble  that  produced 


780  GENITO-URINARY  SURGERY 

by  blows  of  a  hammer,  the  suffering  being  intense  and  the  pain  deeply  placed. 
These  three  types  may  be  associated  or  may  succeed  one  another. 

The  pain  may  be  sharply  circumscribed  to  an  area  not  larger  than  a  half- 
dollar.  In  this  case  it  frequently  indicates  the  formation  of  a  gumma.  Some- 
times it  is  diffuse,  occupying  a  general  region,  as  the  frontal,  temporal,  parietal^ 
or  occipital,  or  is  spread  over  two  or  more  of  these  regions.  Exceptionally  it 
seems  to  involve  the  whole  head.  The  fronto-parietal  region  is  the  one  to 
which  this  pain  is  most  frequently  referred.  This  form  of  cephalalgia  has  three 
characteristics  which  should  at  least  strongly  suggest  its  nature:  1,  there  is  an 
habitual  intensity,  sometimes  extraordinary  severity,  of  pain;  2,  it  is  persistent, 
tenacious,  long-lasting;  3,  there  are  nocturnal  exacerbations. 

Even  in  mild  cases  the  pain  is  less  bearable  than  the  ordinary  headache; 
it  harasses  the  sufferers,  making  them  despondent,  morose,  excitable,  and  sleep- 
less, and  interferes  with  general  nutrition;  or  it  may  be  so  severe  as  completely 
to  prostrate  them.  Exceptionally  the  pain  amounts  to  a  veritable  anguish, 
comparable  in  intensity  to  that  of  hepatic  or  nephritic  colic. 

As  a  rule,  syphilitic  cephalalgia  precedes  the  grave  developments  of  brain- 
syphilis  by  an  interval  of  from  three  to  six  weeks;  it  is,  however,  not  uncommon 
for  this  pain  to  last  from  three  to  six  months ;  exceptionally  the  pain  may  exhibit 
remissions  and  exacerbations  for  two  or  three  years.  Under  the  influence  of 
intermittent  mild  specific  treatment  the  headache  may  be  temporarily  cured, 
to  recur  time  after  time,  till  symptoms  such  as  hemiplegia  or  epilepsy  show 
that  irreparable  damage  has  been  done. 

Nocturnal  exacerbations  of  pain,  though  the  rule,  are  by  no  means  invariable. 
In  the  secondary  period  this  characteristic  is  most  pronounced;  in  the  tertiary 
period  it  may  be  wanting  entirely;  indeed,  there  may  even  be  nocturnal 
remissions. 

Treatment. — The  treatment  should  be  instituted  early,  and  should  be 
sufficiently  thorough  to  cure  the  headache  and  to  eradicate  as  far  as  possible 
the  underlying  constitutional  taint.  Mercury  and  potassium  iodide  should  be 
given  in  the  most  active  manner  possible.  Daily  hypodermic  injections  of 
corrosive  chloride  or  inunctions  of  mercury  ointment  should  be  given  in  full 
doses  supplemented  by  the  vapor  bath.  The  use  of  salvarsan  should  be  post- 
poned till  a  thorough  course  of  mercury  has  been  given.  Internally,  potassium 
iodide  should  be  rapidly  pushed  to  the  extreme  point  of  toleration:  to  a 
woman,  one  to  one  and  a  half  drachms  a  day;  to  a  man,  nearly  twice  this 
dose.  This  treatment  should  be  long  continued,  with  appropriate  short  intervals 
of  rest,  until  there  is  good  reason  to  believe  that  there  is  no  likelihood  of 
recurrence.  Fournier  has  relieved  the  agonizing  cephalalgia  of  high  tension 
by  lumbar  puncture. 

Paras YPHiLTTic  Cephalalgia. — Among  the  parasyphilitic  headaches  may 
be  mentioned  the  neuralgic  migraine  and  the  crises  of  pain  often  observed  in 
tabes.  The  most  important  cause  of  these  headaches,  and  by  far  the  most 
common,  is  neurasthenia.  This  is  an  ordinary  sequel  of  syphilis,  and  among 
its  multitudinous  symptoms  none  is  more  troublesome  or  more  frequent  than 
hearl^rhe. 

This  parasyphilitic  neurasthenic  headache  is  characterized  by  moderate  in- 


SYPHILIS  OF  THE  NERVOUS  SYSTEAI  781 

tensity;  it  is  not  really  a  pain,  but  rather  a  sensation  of  weight  or  constriction, 
of  dulled  or  imperfect  cerebral  action.  It  usually  lasts  several  years.  It  is 
present  in  the  morning  on  rising;  is  sometimes  better  after  meals,  but  shortly 
returns  with  its  original  intensity,  or  even  with  a  slight  excess  of  this;  it  is 
better  at  night,  so  that  sleep  is  not  disturbed.  It  is  not  benefited  by  specific 
treatment;  it  is  usually  located  in  the  occipital  region;  and  it  is  often  associated 
with  other  signs  of  neurasthenia.  These  are  characteristics  which  sufficiently 
distinguish  this  cephalalgia  from  pain  preceding  the  recognized  cephalopathies; 
indeed,  a  headache  which  has  lasted  for  several  years  almost  certainly  does 
not  belong  to  the  latter  class,  since  apoplexy  or  some  one  of  the  serious  symp- 
toms denoting  irreparable  brain-lesion  is  certain  to  develop  long  before  the 
expiration  of  this  period.  Yet  it  may  well  happen  that  a  differential  diagnosis 
cannot  be  made.  In  this  case  the  mixed  specific  treatment  should  be  given 
one  thorough  trial.  Should  it  fail,  there  should  be  no  further  effort  in  the 
direction  of  attempting  cure  by  this  treatment. 

When  the  diagnosis  of  parasyphilitic  neurasthenia  is  firmly  established, 
minute  attention  to  general  hygiene,  thorough  hydrotherapy,  especially  with 
douches  of  brief  duration,  and  congenial  surroundings,  represent  the  best 
methods  of  accomplishing  a  cure.  The  only  drug  which  is  of  the  least  service, 
aside  from  tonics  and  nutritives,  is  potassium  bromide;  this  sometimes  relieves 
the  headache. 

But  we  cannot  affirm  that  all  grave  syphilitic  cerebropathies  are  preceded 
by  these  headaches.  Mauriac  quotes  a  case  in  which  a  man  aged  twenty-two 
was  suddenly  seized  with  severe  convulsions  of  the  left  arm,  which  were  un- 
doubtedly due  to  syphilis,  but  which  were  preceded  by  no  prodromal  head- 
ache or  other  nervous  symptoms.  Fournier  also  has  noted  a  similar  case  wherein 
the  patient  had  suffered  no  headache  during  the  ailment,  and  yet  the  post- 
mortem disclosed  extensive  syphilitic  disease  of  the  brain. 

Following  these  prodromal  symptoms  there  are  certain  symptoms,  which 
Finger  classifies  as  follows: 

1.  Psychical  disturbances,  with  epilepsy  accompanied  by  paresis  not  involv- 
ing the  cerebral  nerves,  terminating  in  coma.  In  these  cases  gummata  and  wide- 
spread endarteritis  of  the  convexity  of  the  brain  are  found. 

Following  the  prodromes  or  without  symptoms  there  is  a  sudden,  often 
violent,  epileptic  attack,  sometimes  not  accompanied  by  complete  loss  of  con- 
sciousness. This  is  followed  by  cerebral  irritability  and  fatigue,  mental 
failure,  progressing  to  dementia,  localized  muscular  weakness,  paresis  or  paraly- 
sis which  may  be  of  irregular  distribution,  and  slow,  halting  speech. 

2.  Apoplectic  attacks  followed  by  hemiplegia  associated  with  somnolence, 
with  S3'm.ptoms  of  irritation  of  one  side  and  paralysis  of  the  cerebral  nerves. 

In  these  cases  there  are  gummatous  infiltration  of  the  base  and  arteritis 
involving  the  vessels  of  the  large  central  ganglia.  Following  prodromal  symp- 
toms there  is  suddenly  developed  palsy  of  one  or  more  cranial  nerves,  the  oculo- 
motor and  abducens  being  most  frequently  involved.  This  will  be  shown  by 
ptosis,  strabismus,  loss  of  accommodation,  etc.  These  palsies  are  persistent,  and 
may  be  preceded  or  accompanied  by  twitchings  or  contractions  of  the  muscles 
supplied  by  the  affected  nerves.    Following  these  symptoms,  or  sometimes  pre- 


782  GEXITO-URIXARY  SURGERY 

ceding  them,  there  is  an  apoplectic  attack,  often  not  attended  by  loss  of 
consciousness,  but  with  hemiplegia  and  disturbance  of  speech.  Even  v/hen 
this  stage  is  reached  almost  complete  restoration  of  mental  power  is  possible. 
If  the  disease  is  progressiye,  other  apoplectic  attacks  supervene,  the  mind 
becomes  dull  and  listless,  there  are  involuntary  micturition  and  defecation,  and 
finally  coma  and  death  super\^ene. 

3.  Psychoses,  appearing  generally  in  the  form  of  paralytic  dementia  or  pro- 
gressive paralysis. 

These  ps3xhoses  are  usualh'  accompanied  by  paresis  or  paralysis,  especially 
of  the  cranial  nerves,  and  b}'  epileptiform  attacks. 

The  syphilitic  cerebropathies  are  most  commonl}^  characterized  by  a  slow  but 
steady  advance;  thus,  a  slight  neuralgia  expands  into  epileptiform  convulsions, 
and  finally  ends  with  paresis  or  paralysis. 

Diagnosis  of  Intracranial  Syphilis. — In  general  it  may  be  affirmed  that 
all  non-traumatic,  non-cardiac  cerebropathies  found  in  persons  of  previously 
good  health  between  the  ages  of  twenty  and  forty  are  probably  of  s)^hilitic 
origin.  If  there  is  a  history  of  preceding  chancre  the  diagnosis  is  still  further 
assured.  Epileps^^  if  idiopathic  or  inherited,  always  makes  its  appearanc^  m 
childhood;  when  it  occurs  late  in  life  and  is  non-traumatic,  it  is  exceptional, 
and  is  then  probabh^  due  to  sv-philis.  In  nervous  disorders  wherein  two 
diatheses  are  possible  causes,  for  instance,  the  gouty  and  the  syphilitic,  the 
diagnosis  is  to  a  certain  extent  dependent  upon  the  therapeutic  test. 

A  gouty  diathesis  is  apt  to  produce  nervous  S3'mptoms  only  late  in  life,  but 
in  all  other  respects  gouty  and  s^-philitic  cerebropathies  may  be  almost  identical. 
In  both  gout  and  syphilitis  arterio-sclerosis  is  a  common  feature,  and  the  same 
symptoms  would  follow  from  whatever  cause  the  lesion  was  produced. 

Even  the  therapeutic  test  is  not  wholly  trustworthy  in  deciding  as  to  the 
specific  nature  of  palsies.  Paralysis  of  the  facial  nerve,  though  strongly  sug- 
gesting syphilis,  is  not  pathognomonic,  since  facial  paralysis  may  be  produced 
by  cold,  and  may  be  only  a  transitory  affection,  which  disappears  under  full 
doses  of  potassium  iodide  simply  because  it  has  run  its  course.  It  is  always 
possible  that  the  parah'sis  ma}^  have  been  an  independent  acute  attack,  and 
might  have  disappeared  of  itself  without  treatment. 

Attention  has  been  called  to  the  fact  that  the  symptoms  of  cerebral  syphilis 
are  often  attributed  to  slight  disorders,  and  hence  treatment  is  not  instituted  at 
the  time  that  it  is  most  valuable. 

In  forming  a  diagnosis  a  minute  study  of  the  previous  history  is  imperative, 
as  w^ell  as  careful  observation  of  the  entire  symptom-complex.  The  diagnosis 
will  then  be  founded  on  a  syphilitic  history,  a  prodromal  headache  persistently 
worse  at  night,  and  often  associated  with  vertigo,  impaired  mental  activity, 
localized  paresis,  epileptiform  or  apoplectiform  attacks,  not  necessarily  attended 
with  loss  of  consciousness,  hemiplegia  and  paralysis  particularly  involving  the 
cranial  nerves,  marked  psychoses,  and  coma.  These  symptoms  are  somewhat 
irregular,  but  progressive.  They  are  checked  by  specific  treatment.  Vertigo 
is  of  significance  only  when  associated  with  headache;  it  is  aggravated  by 
excitement  or  sudden  change  of  posture,  and  mav  merge  into  transient  un- 
consciousness.   Insomnia  is  the  rule  in  patients  under  fifty,  who  are  often  unable 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  783 

to  sleep  at  all  during  the  first  part  of  the  night.  This  insomnia  bears  a  relation 
to  the  intensity  of  the  headache,  and  disappears  with  the  latter  on  the  onset  of 
paralysis.     Somnolence  is  observed  in  patients  over  fifty. 

The  paralysis  that  develops  during  sleep  is  probably  due  to  a  thrombus, 
that  which  occurs  during  brain  activity  is  probably  caused  by  rupture.  Involve- 
ment of  the  third  nerve  is  so  characteristic  of  intracranial  syphilis  that  ptosis 
or  strabismus  developing  suddenly  in  an  adult  is  diagnostic.  Epilepsy  develop- 
ing in  the  adult  is  traumatic,  ursemic,  or  syphilitic,  and  hemiplegia,  if  not 
embolic,  is  usually  of  the  same  nature. 

Examination  of  the  blood-serum  and  of  the  cerebrospinal  fluid  results  in 
more  or  less  suggestive  findings  in  the  majority  of  the  cases.  The  serum 
Wassermann  is  more  frequently  positive  than  that  of  the  fluid  (81  per  cent, 
to  66  per  cent.).  A  pleocytosis  is  found  in  approximately  80  per  cent,  of  cases, 
and  an  increase  of  globulin  with  about  the  same  frequency.  The  Lange  gold 
test  has  been  found  to  give  a  luetic  curve  in  60  per  cent.,  a  paretic  curve  in 
13  per  cent.,  and  a  normal  reaction  in  27  per  cent,  (compilation  of  Miller, 
Brush,  Hammers,  and  Felton). 

Prognosis. — The  prognosis  is  always  grave  unless  energetic  anti-syphilitic 
treatment  can  be  instituted  before  the  syphilitic  lesions  have  produced  actual 
destruction  of  nerve  tissue  from  pressure  incident  to  involvement  of  the  neu- 
roglia and  adventitious  tissues.  In  most  cases  a  guardedly  favorable  prognosis 
can  be  based  on  a  prompt  response  to  specific  treatment.  Meningitis,  gum- 
matous tumors,  many  cases  of  myelitis  and  paralysis  due  to  thromboses  or  to 
endarteritis  obliterans,  offer  a  prognosis  much  more  favorable  than  do  these 
same  conditions  when  due  to  other  causes.  Locomotor  ataxia  is  sometimes 
apparently  made  worse  by  specific  treatment.  Syphilitic  epilepsy  in  its  earliest 
stages  may  be  helped  by  treatment;  later,  because  of  habit,  the  cause  becomes 
of  minor  importance  so  far  as  cure  is  concerned;  moreover  these  patients  are 
often  intolerant  of  iodides.  The  prognosis  is  general  paralysis  of  the  insane, 
and  is  almost  invariably  hopeless;  certainly  nothing  positive  can  be  promised  as 
to  the  final  outcome. 

In  a  large  proportion  of  the  cases  of  intracranial  syphilis,  the  lesion  is  an 
endarteritis  obliterans.  Before  the  obstruction  is  complete,  much  can  be  done 
by  active  treatment. 

Treatment. — The  treatment  for  cerebral  syphilis  is  the  same  as  that  for 
all  tertiary  lesions — namely,  a  mixed  treatment  of  potassium  iodide  and  mer- 
cury. The  potassium  iodide  should  be  started  in  full  doses  of  thirty  to  forty 
grains  daily  and  pushed  rapidly  to  the  point  of  tolerance.  Everything  depends 
upon  obtaining  a  prompt  action,  and  to  begin  with  small  doses  of  five  or 
six  grains  is  a  dangerous  waste  of  time.  The  use  of  salvarsan  should  be  pre- 
ceded by  such  a  course  of  treatment.  The  prodromal  period  is  the  time  to 
avert  irremediable  degenerations  and  to  ward  off  the  violent  nerve-storms  which 
are  sure  to  follow  if  the  treatment  be  neglected.  Hygienic  measures  are  not 
to  be  ignored,  the  nervous  system  must  be  kept  at  rest,  there  must  be  no  house- 
hold or  business  worries,  and  there  must  be,  if  possible,  moderate  and  regular 
exercise.    Attention  to  the  digestive  tract  is  of  the  utmost  importance. 

In  convulsive  types  the  bromides  are  useful;   antipyrin,  chloral,  and  chlo- 


784  GENITO-URINARY  SURGERY 

ralamide  are  at  times  of  great  service  when  the  pains  are  intense.  Electricity- 
should  be  employed  to  exercise  and  stimulate  the  paralyzed  muscles.  When 
rapid  action  of  the  specific  is  imperative,  intramuscular  injections  of  mercury 
are  indicated.  Potassium  iodide  is  most  conveniently  given  in  the  saturated 
solution  of  which  one  minim  contains  one  grain.  The  limit  of  physiological 
toleration  to  these  drugs  should  be  reached  early  and  maintained  by  full  doses. 


.     SYPHILIS  OF  THE  SPINAL  CORD 

Syphilis  of  the  spinal  cord  cannot  be  said  to  have  in  its  symptoms  the 
irregularity  and  incongruity  which  are  the  characteristic  features  of  cferebral 
syphilis.  Myelopathies  due  to  syphilis  correspond  in  every  respect  to  those  due 
to  other  causes.  Syphilis,  however,  is  an  etiological  factor  of  the  greatest  fre- 
quency in  all  myelopathies,  whether  distinguished  by  softening  or  by  sclerosis, 
either  diffuse  or  circumscribed:  so  that  it  is  almost  justifiable  to  assert  that  any 
myelopathy  of  which  the  cause  is  not  manifest  is  syphilitic. 

The  syphilitic  lesions  which  may  affect  the  cord  and  its  membranes  are 
identical  with  those  which  affect  the  brain — namely,  diffuse  gummatous  infil- 
tration followed  by  sclerosis,  circumscribed  gummata,  and  endarteritis.  Mye- 
lopathies occur  with  the  greatest  frequency  during  the  third  or  fourth  year  after 
infection;  cases,  however,  have  been  observed  occurring  as  late  as  twenty-five 
years  after  the  contraction  of  syphilis. 

Etiology. — There  is  no  satisfactory  explanation  as  to  why  syphilis  should 
attack  the  cord  in  some  cases  and  not  in  others.  In  addition  to  the  general 
causes  mentioned  when  treating  of  cerebral  syphilis,  venereal  excess  and,  accord- 
ing to  Mauriac,  the  influence  of  a  damp  cold  climate  should  be  included. 

Morel-Lavallee  thinks  that  there  is  special  virulence  in  the  original  infecting 
germ  of  certain  cases  of  syphilis  which  has  a  predilection  for  the  nervous 
system.  He  cites  from  personal  observation  the  cases  of  five  men  who  con- 
tracted syphilis  from  the  same  source,  and  all  of  whom  died,  at  varying  periods 
after  infection,  from  syphilitic  disease  of  the  nervous  system,  while,  strangely 
enough,  the  woman  who  infected  them  married  and  gave  birth  to  a  healthy 
child.    This  special  virulence  he  calls  the  "  verole  nerveuse." 

As  a  rule,  S3^hilis  does  not  attack  primarily  the  essential  tissues  of  an 
organ — as,  for  instance,  the  nerve-cells  themselves:  hence  gummata  of  the  cord 
are  rare;  they  do  occur,  however,  in  the  centre  of  the  cord,  and  somewhat  more 
frequently  on  its  surface,  adhering  closely  to  the  meninges,  from  which  prob- 
ably they  originate.  They  present  the  same  appearance  as  gummata  of  the 
cerebrum. 

The  most  common  forms  of  syphilitic  myelopathies  are  sclerosis  and  soften- 
ing, which  are  usually  associated  and  which  may  be  widespread  or  circumscribed. 
Softening  often,  not  always,  follows  in  the  path  of  the  sclerosis;  it  is  only 
exceptionally  a  rapid  process,  and  where  symptoms  of  spinal  disorder  have 
existed  for  a  length  of  time  is  commonly  found  in  disseminated  patches.  When 
the  myelopathy  has  advanced  rapidly  and  deep  bed-sores  form  in  the  sacral 
region,  the  softening  is  generally  extensive,  without  patches  of  sclerosis. 

Fibrous  degeneration  or  sclerosis  of  the  cord  is  more  frequent  than  softening. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  785 

but  for  the  most  part  the  two  processes  are  so  intimately  associated  that  they 
may  be  considered  as  but  two  pJtiases  of  the  same  process. 

Lesions  of  the  cord  consequent  upon  syphilis  of  its  bony  envelope  are  far 
less  frequent  than  are  the  corresponding  cerebral  lesions;  possibly  because  of 
the  greater  space  between  the  vertebrae  and  the  nervous  tissue,  and  also  because 
the  vertebrae  have  a  periosteal  envelope  independent  of  the  dura  mater. 

The  meninges  of  the  cord  are  especially  liable  to  be  attacked.  The  mem- 
branes are  so  intimately  associated  that  it  is  almost  impossible  to  distinguish 
in  which  of  the  three  the  lesion  originated,  since  it  always  rapidly  spreads  from 
one  to  the  other,  thus  making  at  the  invaded  point  one  thick  membrane,  possibly 
studded  here  and  there  with  gummatous  deposits. 

Symptomatology. — The  symptoms  of  myelo-syphilis  present  the  same  gen- 
eral characteristics  as  cerebral  syphiloses — namely,  dissemination  of  mani- 
festations, a  marked  tendency  to  temporary  amelioration,  and  recurrences, 
together  with  early  implication  of  the  bladder  and  rectum  and  the  early  de- 
velopment of  bed-sores. 

The  development  of  symptoms  due  to  compression  of  the  cord  by  a  syphih'tic 
osteophyte  is  usually  comparatively  slow,  but  otherwise  the  same  as  from  com- 
pression due  to  any  other  cause.  WTien,  on  the  other  hand,  sv'philitic  disease 
of  the  bone  has  gone  to  such  an  extent  as  to  produce  a  sudden  dislocation 
of  the  vertebrae,  then  symptoms  arise  as  suddenly. 

The  paralytic  and  trophic  symptoms  vary  according  to  the  situation  of 
the  compression  or  degeneration.  The  cervical  region  is  most  frequently 
attacked,  and  if  the  compression  is  only  slight  the  upper  extremities  alone  will 
be  affected.  A  point  of  tenderness  can  almost  always  be  elicited  on  the  spinal 
column  opposite  the  lesion  of  the  cord,  and  in  a  case  of  suspected  cervical  lesion 
an  examination  of  the  throat  should  always  be  made;  there  is  a  possibility  that 
deep  ulcerations  may  indicate  disease  of  the  vertebrae  in  this  region. 

Syphilitic  meningitis  is  rarely  of  an  acute  type;  it  more  commonly  as- 
sumes the  form  of  sclerotic  patches  or  bands  pressing  on  the  cord,  and  is  mani- 
fested in  much  the  same  manner  as  compression  due  to  other  causes.  The  dorsal 
and  lumbar  pains  are  of  excruciating  intensity,  made  worse  by  motion.  Finally, 
paralysis  of  the  extremities  and  sphincters  supervenes,  and  indicates  that  soften- 
ing or  annular  constriction  of  the  cord  has  commenced. 

Acute  or  subacute  myelo-syphiloses  are  not  as  common  as  the  chronic; 
they  are  most  common  in  secondary  syphilis.  When  they  occur  at  a  period 
long  after  the  chancre,  with  no  other  manifestation  of  the  disease,  the  diagnosis 
is  extremely  difficult.  Vesical  troubles  and  weakness  of  the  lower  limbs  are 
usually  the  first  symptoms,  which  rapidly  advance  to  paralysis  and  retention 
of  urine  and  faeces,  followed  shortly  by  incontinence  and  the  formation  of 
deep  bed-sores  on  the  sacrum  and  the  heels.     Fever,  if  any  develops,  is  slight. 

Treatment  is  of  little  avail,  and  death  ensues  in  a  few  days  or  weeks.  This 
acute  myelo-S3qDhilosis  is  the  most  dangerous  of  the  syphilitic  affections  of  the 
cord. 

Chronic  myelo-syphiloses  are  distinguished  not  so  much  by  their  duration 
as  by  the  gradual  development  of  symptoms.     They  are  much  more  common 
than  the  acute  forms,  and  less  likely  to  have  a  rapid  termination. 
50 


786  GEXITO-URIXARY  SURGERY 

The  first  symptoms  are  usually  overlooked,  and  consist  of  neuralgic  pains, 
with  weakness  in  the  limbs.  Slight  difficulties  of  micturition  and  gradual 
enfeeblement  of  sexual  power  follow  in  order.  The  weakness  gradually  develops 
to  paresis  or  paralysis,  and  the  sexual  power  is  entirely  lost.  The  patient  next 
suffers  all  the  excruciating  pains  and  girdle  symptoms  of  myehtis.  It  is  very 
rare  for  disturbances  of  sensation  to  keep  pace  with  the  paralysis.  A  part  of 
the  body  entirely  paralyzed  may  still  retain  its  normal  sensibiHty,  or  else  the 
sensation  may  be  merely  blunted  and  the  patient  be  unable  accurately  to  localize 
the  sensation.  The  reflexes  are  at  first  exaggerated,  but  soon  become  much. 
diminished  or  abolished.  The  symptoms  are  usually  confined  to  the  lower 
extremities,  and  it  is  rare  for  the  process  to  have  a  tendency  to  ascend  the  cord. 

Under  the  influence  of  specific  treatment  the  disease  may  be  occasionally 
checked  or  even  apparently  cured;  but  it  must  be  remembered  that  temporary 
ameliorations  are  characteristic  of  all  s}^hilitic  neuroses. 

Tabes  and  General  Paralysis  of  the  Insane 

Formerly  these  manifestations  of  syphilis  were  styled  "  parasyphilitic  "  or 
"  metas3'philitic  "  affections,  it  being  believed  that  they  were  due  to  various 
causes  acting  upon  soil  prepared  by  the  s\^hilitic  poison.  They  occur  late,  on 
an  average  ten  years  after  the  chancre;  the  patients  usually  bear  no  evidence 
of  tertiary-  S}-philis  in  the  skin  and  bones  (though  the  heart,  aorta,  and  testicles 
are  usually  the  seats  of  lesions  recognizable  with  the  microscope) ;  and  their 
course  is  influenced  little  by  antis3'pliilitic  treatment — sometimes  the  result  of 
such  treatment  is  distinctly  unfavorable.  However,  the  discovery  of  spirochaetes 
in  the  lesions  of  both  diseases  has  settled  the  question  of  their  etiology,  and 
shown  that  they  must  be  considered  as  true  syphilitic  conditions. 

Both  tabes  and  general  paralysis  are  degenerative  lesions  of  the  central 
ner\-ous  system,  the  dorsal  columns  of  the  spinal  cord  being  attacked  in  one 
case,  the  cells  of  the  cerebral  cortex  in  the  other.  The  closeness  of  their  rela- 
tionship is  indicated  by  the  frequency  with  which  the  two  diseases  are  found  in 
the  same  patient;  Mott  states  that  10  per  cent,  of  the  fatal  cases  of  general 
paralysis  have  well-marked  sclerosis  of  the  posterior  columns  of  the  spinal  cord, 
while  if  careful  microscopic  examinations  of  the  brains  of  tabetic  patients  dying 
in  asylums  be  made  almost  all  will  be  found  to  be  tabo-paretics. 

Tabes. — In  its  later  stages  tabes  dorsalis  (locomotor  ataxia)  is  easily  diag- 
nosed even  by  the  layman  by  its  characteristic  gait.  In  this  stage  of  the  disease 
there  is  very  little  to  be  done  for  the  sufferer,  the  diagnosis,  therefore,  being  of 
about  as  much  value  as  there  is  difficulty  in  its  making.  However,  the  marked 
ataxia  which  is  such  a  prominent  symptom  in  the  later  stages  of  the  malady  is 
not  present  at  the  beginning  of  the  degenerative  process,  and  inasmuch  as,  once 
degeneration  has  occurred,  it  is  not  possible  for  the  nervous  elements  to  be 
restored,  it  is  of  the  greatest  importance  that  the  diagnosis  be  made  with  all 
possible  dispatch. 

One  of  the  eariiest  signs  of  tabes  is  the  change  in  the  pupillary  reaction 
known  as  the  Arevil-Robertson  pupil.  This  consists  in  a  loss  of  the  normal 
reflex  contraction  to  light,  while  the  power  of  contraction  with  accommodation 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  787 

and  convergence  is  still  maintained.  This  combination  has  been  noted  but 
rarely  except  in  tabes  and  general  paralysis  of  the  insane.  The  typical  reaction 
is  found  in  over  70  per  cent,  of  cases,  while  in  the  majority  of  the  remainder 
there  are  such  pupillary  abnormalities  as  unilateral  Argyll-Robertson  reaction, 
sluggishness  to  light,  and  complete  immobility  (Mott).  It  is  also  common  to 
find  that  the  pupils  are  irregular  in  shape  and  of  unequal  size.  Unfortunately, 
these  are  not  symptoms  which  the  patient  is  likely  himself  to  observe,  so  they 
are  only  recognized  when  the  disease  is  suspected  for  some  other  reason,  in 
the  course  of  a  careful  routine  examination. 

Usually  patients  apply  for  treatment  because  of  pain  in  some  part  of  the 
body,  or  because  of  failing  eyesight,  or  because  of  trouble  with  urination,  or 
because  of  impotence. 

The  pains  of  tabes  are  usually  of  a  sharp,  sudden,  piercing  character,  often 
called  "  lightning  "  pains,  and  may  be  felt  in  any  part  of  the  body.  The 
individual  pains  are  usually  of  short  duration,  but  the  attacks  last  for  hours 
or  days.  At  other  times  the  pain  is  a  rheumatic  ache.  Girdle  sensations  are 
also  frequently  noted,  as  are  paraesthesias,  such  as  formication,  pins  and  needles, 
and  particularly  a  sensation  in  the  soles  of  the  feet  as  though  the  patient  were 
walking  on  velvet.  All  disturbances  of  sensation  from  hyperaesthesia  to  complete 
anaesthesia  and  analgesia  are  encountered  with  great  frequency.  Anaesthetic 
areas  usually  appear  first  on  the  trunk,  and  commonly  accompany  gastric  crises. 
Blindness,  partial  or  complete,  is  a  fairly  common  and  quite  early  symptom. 
Gradual  peripheral  diminution  of  the  fields  is  the  rule,  due  to  degeneration  of 
the  optic  nerve.  It  has  been  repeatedly  observed  that  there  is  less  tendency  to 
develop  ataxia  in  cases  with  early  optic  atrophy  than  in  others;  but  there  seems 
to  be  a  greater  tendency  to  develop  general  paralysis. 

Of  the  visceral  disturbances,  gastric  crises  and  abnormalities  of  bladder 
control  are  the  most  important.  The  former  consist  in  lancinating  pain  in  the 
region  of  the  stomach,  accompanied  by  vomiting.  Cases  are  also  seen  in  which 
there  is  pain  without  vomiting,  and  occasionally  instances  of  vomiting  without 
pain.  Rectal  crises,  with  severe  tenesmus,  are  also  of  frequent  occurrence. 
Intestinal  crises,  usually  painless,  but  with  numerous  watery  stools,  are  rarely 
seen.  Urinary  disturbances,  chiefly  difficulty  in  starting  the  stream,  loss  of 
projectile  force,  frequency  of  urination,  and,  later,  more  or  less  complete  reten- 
tion of  urine,  are  of  fairly  frequent  occurrence. 

In  the  older  cases  there  is  loss  of  the  sense  of  position  of  joints.  This 
usually  occurs  first  in  the  fingers  and  toes,  later  in  the  other  joints  of  the 
extremities. 

The  ataxia  which  is  responsible  for  the  commoner  name  of  tabes  usually 
develops  at  a  comparatively  late  date,  often  not  till  many  years  after  the 
beginning  of  the  degenerative  process.  It  is  usually  found  first  in  the  lower 
extremities,  and  in  many  cases  these  alone  are  affected;  incoordination  is 
never  observed  in  the  muscles  of  the  neck  and  head. 

Loss  of  the  deep  reflexes  is  one  of  the  earlier  symptoms  of  tabes,  often  pre- 
ceding ataxia  by  several  years.  The  Achilles  tendon  reflex  is  usually  lost 
before  that  of  the  patellar  tendon,  while  loss  of  the  triceps  reflex  is  of  still  later 


788  GENITO-URINARY  SURGERY 

occurrence.    While  the  loss  of  these  reflexes  is  characteristic  of  the  disease,  their 
presence  is  not  altogether  incompatible  with  a  diagnosis  of  tabes. 

Prognosis. — Tabes  dorsalis  shortens  life  very  little.  It  is  typically  a 
chronic  process,  extending  over  years,  and  often,  even  in  the  absence  of  all  treat- 
ment, is  stationary  for  long  periods.  There  is,  of  course,  no  possibility  of 
restoring  the  function  of  atrophied  tracts;  the  most  that  can  be  hoped  for  is 
arrest  of  the  degenerative  process. 

Diagnosis. — This  rests  in  part  on  the  symptomatology,  in  part  on  the 
physical  examination,  and  in  part  on  the  laboratory  findings,  especially  in  the 
earlier  cases.  Schaller  says:  "  In  a  patient  with  a  history  or  other  evidence 
of  syphilis  presenting  characteristic  sensibility  disturbances  of  the  radicular 
type,  with  a  tendency  to  symmetry,  one  should  suspect  a  potential  or  early 
tabes.  If,  associated  with  the  above,  we  have  a  positive  reaction  in  the  cere- 
brospinal  fluid,  indicating  a  chronic  syphilitic  meningitis,  together  with  such 
pupillary  phenomena  as  anisocoria,  pupillary  irregularity,  or  sluggish  reaction 
to  light,  the  diagnosis  of  early  tabes  is  most  probable.  Added  to  the  above 
symptoms,  the  loss  of  the  Achilles  tendon  reflex  establishes  the  diagnosis  of 
early  tabes  even  in  the  absence  of  those  signs  which  we  usually  associate  with 
tabes:  Romberg,  marked  sensibility  loss,  absent  patellar  reflexes,  and  Argyll- 
Robertson  pupils."  The  usual  laboratory  findings  in  tabes  are  a  positive 
Wassermann  in  both  the  serum  (54  per  cent.)  and  the  cerebrospinal  fluid  (48 
per  cent.),  an  increase  in  the  cell  count  in  the  fluid  above  8,  an  increase  in  the 
globulin  content,  and  a  positive  Lange  gold  test  (luetic  curve) .  None  of  these 
tests  are  invariably  positive;  the  gold  test  is  the  most  constant  reaction.  It 
must  be  remembered  that  the  manifestations  of  tabes  are  very  varied,  and  that 
exactly  similar  cases  are  never  seen.  The  diagnosis  must  be  made  by  careful 
consideration  of  the  several  symptoms  presented. 

General  Paralysis  of  the  Insane. — Spirochaetes  can  be  found  in  the 
brains  of  paretics  with  much  more  ease  and  regularity  than  in  the  cords  of 
tabetics.  They  have  been  found  in  all  parts  of  the  brain,  but  most  frequently 
and  in  greatest  numbers  in  the  gray  matter  of  the  frontal  and  limbic  lobes. 
The  organisms  have  been  found  both  post  mortem  and  during  life;  in  the  latter 
case  the  tissue  for  examination  was  removed  by  means  of  a  needle  thrust 
through  a  hole  in  the  skull  made  with  a  dental  drill.  While  syphilis  has  been 
repeatedly  produced  in  the  lower  animals  by  inoculation  with  tissue  from  paretic 
brains,  the  percentage  of  successful  results  has  been  low,  and  the  incubation 
period  in  the  successful  cases  has  been  distinctly  greater  than  when  the  source 
of  supply  has  been  primary  or  secondary  lesions. 

The  anato-pathological  basis  of  the  disease  is  a  progressive  atrophy  of  the 
nervous  elements  starting  and  most  prominent  in  the  cerebral  cortex,  but 
being  evident  also  in  the  advanced  cases  throughout  the  central  nervous  system. 
Moreover,  there  is  evidence  of  meningeal  irritation,  particularly  over  the 
anterior  portion  of  the  cerebral  convexity. 

Clinically  the  disease  is  diagnosed  with  the  greatest  difficulty  in  its  early 
stages,  an  indefinable  change  in  the  disposition  and  mental  attitude  being  the 
only  thing  to  indicate  there  is  aught  amiss.  Later — often  two  or  three  years 
later — the  development  of  delusions,  especially  ones  of  the  grandiose  type,  and 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  789 

of  a  progressive  dementia,  with  the  slurring  speech,  immobile  facies,  tremor 
(especially  of  the  tongue  and  facial  muscles),  pupils  which  are  immobile  or 
sluggish  to  light,  often  irregular  and  unequal,  makes  the  diagnosis  evident. 
The  knee-jerks  are  altered  in  most  cases,  usually  exaggerated.  After  the  de- 
velopment of  well-marked  dementia  half  of  the  cases  die  in  six  months,  while 
most  of  the  remainder  succumb  in  less  than  three  years. 

The  customary  laboratory  findings  are  a  positive  Wassermann  reaction  in 
both  the  serum  (91  per  cent.)  and  spinal  fluid  (90  per  cent.),  and  the  pleocy- 
tosis  and  globulin  increase  typical  of  a  syphilitic  meningitis.  The  Lange  gold 
test  gives  a  curve  of  the  type  5555542100  (see  Chap.  XLIII). 

SYPHILIS  OF  THE  NERVES 

At  any  period  of  the  disease  syphilis  is  liable  to  attack  the  nerves  or  the 
gangha. 

Syphilitic  degeneration  of  the  parenchyma  of  the  nerve  itself  is  rare;  the 
process  usually  takes  place  in  the  network  of  connective  tissue  between  the 
fibres  and  in  the  sheaths  of  the  nerves.  But  wherever  the  lesion  is  situated 
in  the  nerve,  the  symxptoms  are  virtually  the  same,  and  manifest  themselves,  as 
in  other  organic  neuroses,  by  disturbances  of  sensation,  motion,  and  nutrition. 

The  sciatic  nerve  is  perhaps  the  most  frequently  affected,  although  any  one 
of  the  nerves  is  liable  to  attack.  The  pains  produced  by  these  lesions  are  not 
to  be  confounded  with  the  rheumatoid  neuralgias  which  occur  early  in  the 
secondary  stage,  and  which  are  in  reality  only  sHght  functional  disorders  and 
not  the  result  of  true  neuritis;  nor  with  the  pain  caused  by  small  periosteal 
tumors,  such,  for  instance,  as  those  formed  upon  the  sternum  and  the  ribs. 

The  suffering  caused  by  S3^hilitic  neuritis  is  intense,  and  frequently  accom- 
panied by  contractions  of  the  muscles,  paresis,  and  paralysis.  The  early 
sciaticas — those  occurring  at  the  beginning  of  the  secondary  stage — are  readily, 
cured  by  specific  treatment,  and  rarely  last  more  than  a  week  or  two;  coming 
on  later  in  the  disease  and  accompanied  by  evidences  of  degeneration,  they 
are  much  more  serious,  and  are  then  probably  due  to  sclerosis  or  gumma 
formation  in  the  connective  tissue  and  substance  of  the  nerve. 

In  like  manner  neuralgias  of  the  occipital  and  cervical  nerves  are  of  slight 
import  in  the  early  secondary  stage,  but  when  occurring  in  the  tertiary  period 
they  are  to  be  regarded  as  grave  symptoms  of  disease  of  the  cervical  vertebra. 

Syphilis  not  uncommonly  attacks  the  cranial  nerves  and  the  nerves  of  special 
sense.  The  lesions  may  be  of  the  nerves  themselves,  or  of  their  sheaths,  or 
of  their  canals  of  exit  from  the  skull;  or  the  symptoms  may  be  due  to  the 
presence  of  neighboring  gummata. 

In  any  event  there  will  probably  be  paralyses  or  possibly  contractions  of 
the  muscles  which  the  involved  nerves  supply.  Although  the  symptoms  are  the 
same  as  from  neuritis  dependent  upon  other  causes,  a  history  of  syphilis  affords 
sufficient  justification  for  assuming  that  the  lesions  are  specific  and  for  treating 
them  as  such.  If  they  occur  at  a  period  remote  from  other  syphilitic  mani- 
festations they  must  be  diagnosed  by  the  method  of  exclusion  or  by  applying 
the  therapeutic  test. 


$^90  GENITO-URINARY  SURGERY 

The  earlier  the  symptoms  of  nerve-involvement  appear  in  the  disease  the 
more  favorable  is  the  prognosis. 

The  optic  nerve,  according  to  Charcot,  may  be  the  seat  of  fibrous  meta- 
morphosis incident  to  parenchymatous  neuritis.  The  lesion  of  the  optic  nerve 
is  usually  a  phenomenon  of  late  appearance,  and  depends  more  or  less  upon 
cerebro-syphiloses. 

The  sense  of  smell  is  affected  when  pachymeningitis  of  the  anterior  cerebral 
fossa  causes  pressure  upon  the  olfactory  lobes:  it  may  also  be  impaired  by 
extensive  destruction  of  the  bones  and  the  mucous  membrane  of  the  nose. 

In  like  manner  the  auditory  nerve  is  affected  either  by  central  lesion  or 
by  the  destruction  of  its  bony  envelope. 

Of  all  the  cranial  nerves  the  motor  oculi,  or  third  pair,  is  the  one  most  fre- 
quently affected.  Paralysis  of  these  nerves  often  makes  its  appearance  early  in 
the  secondary  stage,  but  is  then  only  a  transitory  affection.  When  the  lesion 
is  deep-seated  the  symptoms  will  be  ptosis,  dilatation  of  the  pupil,  external 
strabismus,  and  paralysis  of  accommodation. 

Possibly  mydriasis  may  be  the  only  symptom;  this  has  been  found  to  be  the 
case  when  the  lesion  is  situated  near  the  lenticular  ganglion  and  cuts  off  only 
the  short  ciliary  branches  of  the  nerve. 

The  fourth  pair  is  rarely  affected. 

Lesions  of  the  fifth  pair  are  common,  and  are  manifested  by  neuralgias  or 
h5^eraesthesias  of  any  or  all  of  its  branches. 

Affections  of  the  sixth  pair  are  rare;  they  are  accompanied  by  diplopia, 
convergent  strabismus,  and  orbital  neuralgia. 

The  seventh  pair  of  nerves  exhibits  a  peculiarity  in  that  it  is  so  often 
affected  early  in  the  disease,  at  times  within  a  few  weeks  of  the  appearance 
of  chancre. 

The  symptoms  vary  according  to  the  situation  of  the  lesion :  if  it  is  situated 
on  the  main  trunk  of  the  nerve  within  the  Fallopian  canal,  or  beyond  it, 
paralysis  of  the  face  is  the  only  symptom;  if  it  is  situated  within  the  skull, 
the  usual  symptoms  of  intracranial  lesion — headache,  vertigo,  aphasia,  con- 
vulsions, etc. — are  also  present. 

The  other  cranial  nerves  are  rarely  affected. 


CHAPTER  XXXVIII 

SYPHILIS  OF  THE  EYE,  EAR  AND  RESPIRATORY  TRACT 

Chancre  may  develop  on  the  eyelid  or  on  the  conjunctiva.  Beginning  as 
a  pimple,  the  lesion  gradually  develops  into  a  characteristic,  saucer-shaped 
ulceration,  with  rounded  edges  and  indurated  base. 

Secondary  syphilis  may  appear  upon  the  eyelids,  as  well  as  gummata  of  the 
skin  and  so-called  tertiary  ulcers. 

Syphilitic  tarsitis  is  an  inflammation  of  the  tarsus,  which  produces  great 
thickening  of  the  lids,  and  in  some  instances  is  due  to  a  diffuse  gummatous 
infiltration.  More  rarely  it  is  acute,  and  then  must  not  be  mistaken  for  an 
ordinary  strumous  inflammation  of  the  ciliary  border,  from  which  it  is  to  be 
distinguished  by  the  thickening  and  induration  of  the  tarsus. 

Syphilitic  conjunctivitis  hjis  been  described  in  a  few  instances,  the  appear- 
ances being  somewhat  analogous  to  those  of  granular  lids,  the  disease  \'ielding, 
however,  only  to  antisyphilitic  remedies. 

Syphilitic  periostitis  may  attack  the  orbital  margins  either  in  a  gummatous 
or  in  a  sclerosing  form.  When  the  orbital  walls  are  involved  behind  the  capsule 
of  Tenon,  the  type  is  almost  always  gummatous.  The  symptoms  are  then 
pain,  worse  at  night,  restriction  in  the  mobility  of  the  globe,  squint,  and  diplopia. 
As  complications  there  may  be  optic  neuritis  and  inflammation  of  the  cornea. 

Caries  of  the  margin  of  the  orbit  is  not  uncommon  in  syphilis,  usually  as 
the  result  of  preexisting  periostitis. 

Syphilis  of  the  Lachrymal  Apparatus. — Occasionally  the  lachrj-mal 
gland  becomes  enlarged  and  indurated  as  the  result  of  syphilis,  and  hypertrophy 
of  this  body,  appearing  as  an  indurated  lobulated  tumor,  having  its  situation 
in  the  upper  and  outer  part  of  the  orbit,  should  always  be  given  careful  anti- 
syphilitic  treatment  before  surgical  measures  are  adopted. 

Occasionally  a  lachrymal  abscess  forms  in  children  above  the  internal  pal- 
pebral ligament  and  external  to  the  sac  itself:  hence  the  name  prelachrymal 
abscess;   it  is  usually  due  to  inherited  syphilis. 

The  lachrymal  sac  and  nasal  duct  may  become  obstructed  through  periostitis 
and  caries  of  the  lachrymal  bone  or  the  pressure  of  gummatous  deposits.  The 
lachrymal  apparatus  in  its  entirety  is  singularly  free  from  manifestations  of 
syphilis. 

Syphilitic  Affections  of  the  Cornea. — Interstitial  Keratitis  (syphiHtic, 
inherited,  specific,  parenchymatous,  or  diffuse  keratitis.) — This  is  a  chronic 
inflammation  of  the  whole  thickness  of  the  cornea,  the  membrane  gradually 
passing  into  a  condition  of  universal  thick  haziness,  associated  with  vasculariza- 
tion, but  almost  always  without  ulceration. 

Etiology. — Inherited  syphilis  is  the  cause  in  between  sixty  and  seventy 
per  cent,  of  the  cases.  Very  rarely  perfectly  typical  examples  appear  with 
acquired  syphilis.     It  is  described  under  hereditary  syphilis. 

791 


792  GENITO-URINARY  SURGERY 

Punctate  keratitis,  characterized  by  the  deposition  of  opaque  dots  arranged 
in  a  triangular  manner  upon  the  posterior  elastic  lamina  of  the  cornea,  is  usually 
an  indication  of  affections  of  the  iris,  choroid,  and  vitreous,  but  may  also  appear 
both  with  and  without  iritis,  and  as  a  syphilitic  inflammation.  It  occurs  in 
the  late  or  gummatous  period  of  syphilis,  but  is  seen  also  in  children  before 
puberty  as  one  of  the  forms  of  inherited  syphilis.  The  treatment  is  the  same 
as  that  described  under  interstitial  keratitis. 

Syphilis  of  the  Sclera. — A  certain  number  of  cases  of  scleritis  and 
episcleritis — that  is,  inflammation  of  the  sclera  itself  or  its  overlying  tissue — 
have  been  ascribed  to  acquired  syphilis  and  yielded  to  the  ordinary  remedies. 
So,  also,  in  the  late  stages  of  syphilis,  a  true  gummatous  scleritis  may  develop, 
characterized  by  the  formation  of  yellowish-brown  and  semi-translucent  nodules 
on  this  membrane. 

Syphilis  of  the  Iris. — Fifty  per  cent,  of  all  cases  of  iritis  are  syphilitic, 
and  are  frequently  associated  with  choroiditis. 

There  are  four  distinct  varieties  of  the  affection. 
•  1.  Syphilitic  Plastic  Iritis. — This  may  occur  in  the  early  stages  of  general 
syphilis,  usually  between  the  second  and  the  ninth  month  after  the  initial  lesion, 
and  is  characterized  by  the  ordinary  symptoms  of  iritis — namely,  fine  peri- 
corneal injection,  contracted  sluggish,  or  immobile  pupil,  discolored  iris,  abnor- 
mal reaction  to  a  mydriatic,  slight  tenderness  on  pressure,  the  formation  of 
attachments  between  the  margin  of  the  iris  and  the  capsule  of  the  lens  (pos- 
terior synechiae),  and  severe  pain  in  the  brow  and  head,  worse  at  night. 

The  symptoms  do  not  differ  from  those  of  a  simple  iritis  from  other  causes, 
and  are  of  themselves  not  characteristic  of  the  disease,  yet  the  lesions  are  due 
to  the  syphilitic  taint  and  yield  to  the  ordinary  constitutional  remedies  and 
local  measures. 

2.  Syphilitic  parenchymatous  iritis  is  an  accompaniment  of  secondary 
syphilis,  and  is  characterized  by  a  deposit  of  yellowish-red  nodules  on  the 
ciliary  or  the  pupillary  border  of  the  inflamed  iris,  comparable  to  the  papules 
and  condylomata  of  the  stage  at  which  it  occurs,  and  hence  called  iritis  papulosa 
or  condylomatous  iritis.  These  small  nodules  vary  in  number  from  one  to 
four,  and  are  gradually  absorbed  under  treatment,  leaving  faint  scars  in  the 
iris-tissue  to  mark  their  former  situation.  Sometimes  instead  of  distinct  nodules 
there  are  local  swellings  in  the  iris-tissue,  the  membrane  being  attached  at  these 
situations  by  broad  and  moderately  soft  synechiae  to  the  capsule  of  the  lens, 
causing  fixed  distortion  of  the  pupil,  often  "  umbrella  "  iris,  and  impairment 
or  loss  of  vision. 

3.  Gummatous  iritis — gumma  of  the  iris — occurs  in  the  late  or  tertiary 
stages  of  syphilis,  and  is  characterized  by  the  development  of  large  yellowish 
nodules,  usually  on  the  ciliary  border  of  the  iris,  and  strongly  analogous  to 
gummata  elsewhere  in  the  body. 

Occasionally  at  this  late  stage  an  iritis  unassociated  with  nodules  appears, 
somewhat  resembling  the  plastic  type  of  the  disease,  and  probably  the  relapse 
of  a  plastic  iritis  which  occurred  in  an  early  stage,  owing  to  a  failure  in  the 
absorption  of  the  original  synechiae. 

4.  Serous  iritis  (more  properly,  serous  cyclitis),  characterized  by  a  serous 
or  sero-plastic  exudate,  deepening  of  the  anterior  chamber,  slight  dilatation  of 


SYPHILIS,  EYE,  EAR,  AND  RESPIRATORY  TRACT  793 

the  pupil,  haziness  of  the  cornea,  and  opaque  dots  on  its  posterior  elastic  mem- 
brane arranged  in  a  triangular  manner,  is  an  unusual  variety  of  iritis  as  the 
result  of  acquired  syphilis  in  the  secondary  stage,  although  common  frotn 
many  other  causes. 

Inherited  syphilis  may  also  produce  iritis,  the  disease,  characterized  by  much 
exudation  and  rapid  occlusion  of  the  pupil,  usually  appearing  between  the  ages 
of  two  and  fifteen  months,  and  being  very  much  more  frequent  in  girls  than  in, 
boys.    It  is  probable  that  all  iritis  occurring  in  young  children  is  due  to  syphilis. 

Subacute,  chronic,  and  so-called  quiet  iritis  may  also  be  caused  by  syphilis, 
the  latter,  as  its  name  imiplies,  being  unassociated  with  much  pain  or  ciliary 
congestion,  the  progressive  dimness  of  vision  usually  leading  to  its  discovery. 

Prognosis. — The  prognosis  of  the  various  types  of  syphiHtic  iritis  is  good, 
provided  the  cases  are  seen  early,  before  firm  adhesions  form  and  much  exuda- 
tion pours  out  into  the  pupillary  space,  causing  either  its  occlusion  or  its  exclu- 
sion. When  thoroughly  treated,  relapses  are  infrequent.  Commonly  both 
eyes  are  attacked,  one  a  little  later  than  its  fellow;  occasionally  the  onset  is 
simultaneous. 

Treatment, — This  should  consist  in  the  free  use  of  atropine  drops,  four 
grains  to  the  ounce,  hot  compresses  and  leeching  the  temple  to  relieve  pain 
and  enhance  the  action  of  the  atropine,  and  the  persistent  use  of  such  anti- 
syphilitic  remedies  as  are  indicated  by  the  stage  at  which  the  iritis  appears. 
In  stubborn  cases,  and  especially  in  gummatous  iritis,  subconjunctival  injections ' 
of  bichloride  of  mercury  may  be  used  with  benefit.  Success  depends  upon 
beginning  the  treatment  early  enough  to  tear  loose  the  synechise  by  the  use 
of  atropine,  which,  except  in  the  .cases  of  serous  iritis  where  there  is  a  tendency 
to  rise  of  intra-ocular  tension,  must  be  vigorously  used  until  all  signs  of 
irritation  have  passed  away  and  a  perfectly  round  pupil  is  obtained. 

Syphilis  of  the  Ciliary  Body. — Independently  of  the  fact  that  this  struc- 
ture is  commonly  involved  in  all  the  severe  types  of  inflammation  of  the  iris, 
forming  the  so-called  irido-cyclitis,  and  that  serous  iritis  is  really  a  manifestation 
of  inflammation  of  the  ciliary  body,  syphilis  strictly  confined  to  this  structure  is 
uncommon.  In  a  few  instances,  however,  gummata  thus  located  have  been 
described. 

The  treatment  of  cyclitis  of  syphilitic  origin,  or,  more  properly,  irido-cyclitis, 
does  not  differ  from  that  of  iritis. 

Syphilis  of  the  Choroid,  Retina,  and  Optic  Nerve. — The  most  im- 
portant lesions  of  these  structures,  discoverable  only  with  the  ophthalmoscope, 
are  the  following: 

Deep  choroiditis,  characterized  in  its  diffuse  exudative  variety  by  yellowish- 
white  plaques,  going  on  later  to  absorption,  heaping  of  pigment,  and  atrophy 
of  the  retina  (choroido-retinitis),  and  in  its  disseminated  variety  by  the  forma- 
tion of  numerous  round  and  oval  spots  in  the  fundus  oculi,  which  have  a 
characteristic  punched-out  look  and  the  margins  of  which  are  bordered  with 
black  pigment.  In  the  later  stages  opacities  in  the  vitreous  humor  are  com- 
mon, and  atrophy  of  the  optic  nerve  may  take  place.  Vision  is  often  seriously 
affected,  especially  if  the  region  of  the  macula  is  involved. 

The  various  types  of  choroiditis  which  are  due  to  acquired  syphilis  appear 


794  GENITO-URINARY  SURGERY 

from  six  months  to  two  years  after  the  initial  lesion;  sometimes  ten  years  elapse 
before  their  appearance. 

Choroiditis  of  similar  type  may  be  due  to  inherited  syphilis,  and  develops 
between  the  sixth  month  and  the  third  year  of  life.  The  treatment  consists  in 
the  exhibition  of  the  usual  antisyphilitic  remedies.  Subconjunctival  injections 
of  sublimate  are  said  to  be  especially  efficacious. 

There  are  a  number  of  other  types  of  choroiditis  which  probably  depend 
upon  syphilis,  but  that  named  is  the  most  important. 

Syphilitic  retinitis  occurs  in  various  types.  The  first  variety,  ordinarily 
called  choroido-retinitis,  is  really  a  disease  of  the  choroid.  The  most  important 
symptoms  are  opacity  of  the  vitreous  (syphihtic  hyalitis),  usually  in  the  form 
of  dust-like  particles;  loss  of  transparenc}^  of  the  retina  around  the  head  of 
the  optic  nerve,  which  is  unduly  hypersemic;  and  numerous  yellow  or  white 
spots  of  exudation  bounded  by  pigment  lying  beneath  the  vessels  of  the  retina. 
Vision  is  much  affected,  especially  in  dim  lights,  the  field  of  vision  is  contracted, 
and  the  patient  complains  of  shimmering,  spots,  circles,  dancing  lights,  and 
distortion  of  objects. 

Sometimes  the  disease  is  more  truly  located  in  the  retina,  which  becomes 
affected  with  a  gray  opacity,  the  optic  nerve  entrance  being  yellowish  red  in 
color,  while  floating  opacities  arise  in  the  vitreous;  occasionally  there  are 
hemorrhages. 

Of  an  unusual  type  and  one  belonging  to  the  late  manifestations  is  a  central 
retinitis,  located  largely  in  the  macular  regions,  and  characterized  by  the  appear- 
ance of  numerous  yellow  or  yellowish-white  spots  and  pigment-dots. 

Retinitis  may  occur  both  in  congenital  and  in  acquired  syphilis.  In  the 
acquired  form  it  appears  usually  from  one  to  two  years  after  infection,  but 
sometimes  as  early  as  the  sixth  month.     Generally  both  eyes  are  involved. 

In  the  hereditary  disease  it  arises,  like  choroiditis,  between  the  sixth  month 
and  the  third  year  of  life. 

The  treatment  consists  in  the  exhibition  of  the  ordinary  antisyphilitic 
remedies,  which  should  be  vigorously  pushed  in  order  to  prevent  secondary 
changes  in  the  optic  nerve  and  consequent  blindness.  The  eye  should  be  pro- 
tected with  dark  glasses,  and  the  accommodation  paralyzed  with  a  weak 
solution  of  atropine. 

Syphilitic  optic  neuritis,  characterized  by  swelling  of  the  nerve-head,  dis- 
tention of  the  veins,  which  become  darker  in  color  and  tortuous,  and  hemor- 
rhages upon  the  swollen  papilla  or  in  its  immediate  neighborhood,  may  be 
caused  by  the  formation  of  an  intracranial  product,  for  example^  a  gumma, 
or  may  develop  as  an  essential  sign  of  syphilis. 

Rapid  mercurialization  should  be  practised,  to  be  followed  later  by  the 
iodides,  and  if  the  exudation  is  quickly  absorbed  the  prognosis  as  to  vision  may 
be  good;  otherwise  the  tissues  are  strangled,  and  there  results — 

Atrophy  of  the  Optic  Nerve. — In  addition  to  this  consecutive  atrophy  of 
the  optic  nerve  the  result  of  a  syphilitic  neuritis,  a  primary  atrophy  occurs, 
observed  in  tabes  dorsalis. 

The  usual  symptoms  of  optic  nerve  atrophy  are  progressive  loss  of  vision, 
ever-increasing  restriction  of  the  field  of  vision,  and  the  ophthalmoscopic  appear- 
ances of  atrophy — namely,  pallor  of  the  disk,  absence  of  capillaries,  and  shrink- 
ing of  the  size  of  the  vessels. 


SYPHILIS,  EYE,  EAR,  AND  RESPIRATORY  TRACT  795 

Syphilitic  Palsies  of  the  External  Ocular  Muscles. — The  most  fre- 
quent cause  of  paralysis  of  the  external  ocular  muscles  is  syphilis,  fully  one- 
half  of  the  cases  having  this  origin.  The  usual  lesion  is  an  inflammation  oi 
gummatous  change  affecting  the  nerve  at  the  base  of  the  brain,  or  in  the  orbit, 
or  there  may  be  disease  of  the  nuclei  of  the  nerves  or  of  the  brain  in  theii 
immediate  vicinity,  or,  finally,  the  lesions  may  exist  in  the  third  ventricle, 
in  the  aqueduct  of  Sylvius,  or  in  the  fourth  ventricle.  Syphilitic  paralysis  is 
usually  but  not  always  one  of  the  late  manifestations  of  syphilis.  The  oculo- 
motor nerve  is  the  one  most  frequently  affected.  The  involvement  is  often  a 
forerunner  of  tabes  or  general  paralysis. 

In  rare  instances  there  is  paralysis  of  the  ocular  muscles  as  the  result  of 
inherited  syphilis. 

The  usual  symptoms  of  palsy  of  the  ocular  muscles  are  present — namely, 
double  vision,  strabismus,  Hmitation  of  movement  in  the  direction  of  the 
affected  muscles,  vertigo,  and  an  altered  position  of  the  carriage  of  the  head, 
which  is  apt  to  be  turned  in  the  direction  in  which  the  patient  is  least  troubled 
by  the  double  images. 

Ophthalmoplegia  is  a  term  used  to  characterize  a  loss  of  power  in  one  or 
more  of  the  eye-muscles,  which  gradually  increases  and  involves  other  muscles 
until  all  of  them  may  be  paralyzed.  This  may  be  caused  by  hereditary  and 
also  by  constitutional  syphilis. 

In  addition  to  the  paralysis  of  the  external  muscles  of  the  eye  there  are 
various  conditions  of  the  pupil  and  ciliary  body  which  arise  under  the  influence 
of  syphilis;  thus,  if  the  oculo-motor  is  paralyzed  and.  those  branches  which 
supply  the  iris  and  the  ciliary  body  are  affected,  there  will  be  dilation  of  the 
pupil  and  loss  of  accommodation.  Occasionally  there  is  a  wide  dilatation  of 
one  pupil  without  affection  of  the  ciliary  body,  and  inequality  of  the  pupils 
may  arise  in  the  course  of  a  focal  syphilitic  brain-lesion.  The  treatment  of 
these  ocular  palsies,  both  external  and  internal,  demands  the  use  of  mercury 
and  ascending  doses  of  potassium  iodide. 

SYPHILIS  OF  THE  EAR 

The  auricle  and  meatus  may  exhibit  any  of  the  characteristic  lesions  of 
constitutional  syphilis. 

In  the  secondary  stage  of  the  disease  dry  or  moist  papules  are  observed. 
These  when  they  involve  the  meatus  are  prone  to  ulcerate  or  to  form  papular 
overgrowths,  accompanied  by  marked  purulent  secretion.  As  a  result  of  free 
suppuration  and  blocking  of  the  canal,  perforation  of  the  drum  and  suppurative 
disease  of  the  middle  ear  may  result.  Condylomata  are  the  most  frequent 
specific  lesions  of  the  meatus. 

Gummata  of  the  external  auditory  meatus  appear  in  the  form  of  moderate- 
sized  chronic  abscesses.     These  are,  however,   extremely  rare. 

The  middle  ear  if  involved  shows  the  changes  incident  to  catarrhal  inflamma- 
tion.   This  is  usually  secondary  to  suppurating  lesions  of  the  throat. 

The  pharyngeal  opening  of  the  Eustachian  tube  is  frequently  the  seat  of 
chancre — the  infection  being  carried  by  the  Eustachian  catheter — of  mucous 
patches,  and  of  gummata.  Cicatricial  contraction  following  these  lesions  may 
completely  block  the  Eustachian  tube.     Syphilitic  otitis  media  may  assume  the 


796  GENITO-URINARY  SURGERY 

suppurative  or  the  sclerosing  form.  Meningitis,  sinus  thrombosis,  facial  palsy^ 
and  the  other  complications  of  non-specific  middle-ear  disease  may  develop. 
Local  treatment  is  of  cardinal  importance. 

The  labyrinth  is  exceptionally  attacked  in  the  early  secondary  stage  of  the 
disease;  usually  this  is  a  late  tertiary  manifestation,  and  it  is  much  more  fre- 
quent in  congenital  than  in  acquired  syphilis.  Tinnitus,  vertigo,  and  sudden 
onset  of  deafness  are  the  chief  symptoms. 

Diagnosis. — This  is  founded  on  the  history  of  syphilis  and  the  absence  of 
other  discoverable  cause  for  disturbance  of  hearing.  The  rapid  onset  of  deafness 
is  also  characteristic.  The  prognosis  always  should  be  guarded.  The  most 
severe  cases  sometimes  recover  promptly  as  the  result  of  specific  treatment;  the 
mildest  cases  may  remain  uninfluenced  by  mercury  and  the  iodides. 

Treatment. — This  when  the  meatus  is  involved  should  comprise  thorough 
cleansing,  the  use  of  astringents,  and  the  application  of  cauterants  to  ulcerating 
spots.  Extensive  overgrowths  and  polypi  should  be  detached  by  snaring  or 
curetting. 

When  the  labyrinth  is  involved  the  specific  treatment  should  be  pushed  to 
its  extreme  limit.    The  prognosis  is  unfavorable  in  these  cases. 

SYPHILIS   OF   THE    RESPIRATORY   TRACT 

Syphilis  of  the  Nose. — Primary  lesions  of  the  nose  are  extremely  rare. 
i\  few  cases  are  recorded  due  to  the  use  of  infected  instruments,  and  in  some 
instances  the  disease  has  arisen  from  unnatural  practices. 

Secondary  manifestations,  in  the  form  of  moist  papules,  frequently  appear 
about  the  nostrils. 

Gummata  involving  the  external  nose  exhibit  a  predilection  for  the  wings, 
the  point,  the  cartilaginous  septum,  and  the  neighborhood  of  the  tear-ducts. 
These  gummata,  beginning  first  in  the  subcutaneous  tissues,  extend  in  depth, 
involving  the  bones  or  cartilages  beneath.  When  there  is  also  gummatous 
infiltration  of  the  walls  of  the  nasal  cavity  marked  deformity  results. 

Syphilis  of  the  Nasal  Cavities. 

1.  Syphilitic  rhinitis. 

Acute. 

Chronic;  hypertrophic, 
atrophic. 

2.  Gummata. 

Nodular. 
Infiltrating. 
Acute  Syphilitic  Rhinitis. — Acute  rhinitis,  one  of  the  most  frequent 
secondaries  of  hereditary  syphilis,  is  comparatively  rare  in  the  acquired  form 
of  the  disease.  It  begins  much  as  does  a  simple  catarrhal  rhinitis,  and  at  first 
cannot  be  distinguished  from  this  affection;  later  it  develops  one  of  the  chief 
characteristics  of  syphilis, — polymorphism.  If  the  nasal  cavities  are  examined, 
the  inflammation  will  be  found  to  vary  in  intensity  even  in  different  parts  of 
the  same  nostril.  Ecchymoses,  abrasions,  superficial  ulcerations,  and  at  times 
mucous  patches  may  be  seen,  particularly  on  the  septum  and  the  lower  turbinals. 
The  posterior  nares  are  at  first  but  slightly  involved ;  later  they  show  the  char- 


SYPHILIS,  EYE,  EAR,  AND  RESPIRATORY  TRACT  79/ 

acteristic  thickening,  h^persemia,  and  dusky  redness  of  acute  inflammation;  by 
this  ^ime  deeper  lesions  will  have  developed  anteriorly. 

Acute  specific  rhinitis  differs  from  the  catarrhal  inflammation  by  persisting 
in  spite  of  careful  treatment  and  by  giving  blood-stained  discharge  or  hemor- 
rhage not  at  the  beginning  of  the  attack,  but  later  when  erosions  and  ulcers 
have  developed.  Usually  the  accessory  nasal  cavities  are  but  slightly  involved. 
Hj-pertrophic  and  ultimately  atrophic  rhinitis  may  be  the  direct  sequelae  of  the 
acute  inflammation. 

Hypertrophic  rhinitis  presents  a  spongy,  swollen,  polypoid  mucous  mem- 
brane, so  thickened  that  practically  no  breathing-space  is  left.  Ulceration 
is  often  present,  particularly  on  the  nasal  septum,  the  lesion  here  being  sharply 
defined  and  exhibiting  an  unhealthy,  readily  bleeding  surface. 

The  secretion  is  abundant,  often  blood-stained  and  stinking.  The  mucous 
membrane  of  the  maxillary,  frontal,  and  sphenoidal  sinuses  may  become  in- 
volved, causing,  from  retained  secretions,  severe  headache  or  neuralgic  pain, 
and  finally  abscess.  Since  the  mucous  membrane  is  closely  applied  to  the 
nasal  bones  and  cartilages,  particularly  that  overlying  the  lower  turbinals, 
perichondritis,  periostitis,  ostitis,  caries,  and  necrosis  generally  complicate 
chronic  specific  rhinitis.  Bone-  or  cartilage-involvement  commonly  gives  rise 
to  no  subjective  symptoms  beyond  deformity  and  blood-stained  discharge, 
complete  perforation  of  the  septum  often  taking  place  without  the  patient 
being  aware  of  it.  The  nostrils  may  be  so  effectively  closed  that  mouth-breath- 
ing, with  its  evil  consequences,  results.  The  sense  of  smell  may  be  lost,  and 
the  tear-ducts  may  be  chronically  inflamed  or  may  be  obliterated. 

Atrophic  rhinitis  follows  the  hypertrophic  inflammation,  or  may  be  caused 
hy  the  wasting  which  follows  gummatous  infiltration.  The  turbinals  are  often 
involved  in  the  atrophic  process,  and  may  be  covered  by  thick  offensive  crusts 
concealing  ulcerations.  The  abnormal  roominess  of  the  nasal  cavities,  the 
thin,  bloodless,  scar-like  mucous  membrane,  and  the  fetor  are  characteristic 
of  atrophic  rhinitis,  whether  it  be  specific  or  not. 

Diagnosis. — The  diagnosis  of  chronic  syphilitic  rhinitis  must  be  based  on 
a  specific  history  or  associated  signs  of  the  disease,  since  it  does  not  differ 
from  the  catarrh  observed  in  non-syphilitics,  particularly  in  those  of  a  stru- 
mous diathesis. 

Gummata. — These  lesions  when  they  are  developed  in  the  nasal  cavity  are 
usually  late  tertiaries.  If  not  treated  promptly  and  energetically  they  produce 
conspicuous  and  irremediable  deformity  of  the  external  nose.  They  appear 
as  distinct  nodules  or  as  diffuse  infiltrations. 

The  gummatous  nodule  attacks  by  preference  the  cartilaginous  septum 
and  the  floor  of  the  nasal  canals.  Occasionally  it  is  found  on  or  near  the 
alar  cartilages.  It  is  usually  single,  grows  slowly,  rarely  reaching  the  size 
of  a  small  cherry,  and  is  often  associated  with  S}'philitic  rhinitis  or  gum- 
matous infiltration.  Though  painless  in  its  course,  if  untreated  it  commonly 
erodes  the  underlying  cartilage  or  bone.  The  resulting  deformity  is  much  less 
than  that  incident  to  the  breaking  dowoi  of  gummatous  infiltration.  Gum- 
mata growing  from  the  mucous  membrane  covering  the  alar  cartilages  per- 
forate the  latter  and  open  into  the  nasal  cavity.     WTien  they  originate  in  the 


798 


GENITO-URINARY  SURGERY 


cartilage  itself  the  perforation  may  be  external.  In  the  latter  case  ulceration 
may  extend  to  the  lower  border  of  the  cartilage,  and  be  followed  by  a  peculiar 
pinching  deformity,  which  may  be  symmetrical. 

Gummata  on  the  floor  of  the  nose  are  rarely  detected  until  they  have 
broken  down  and  formed  ulcers,  or  until  they  have  opened  into  the  mouth. 
The  upper  portion  of  the  nasal  cavity  is  rarely  attacked  by  the  nodular  gumma. 

Gummatous  infiltration  is  the  affection  which  causes  the  most  marked  nasal 
deformities.    It  involves  both  the  mucous  membrane  and  the  underlying  perios- 


FiG.   414.- 


-Gummatous  ulceration  destroying  the  nose.     (From  the  collection  of 
photographs  of  Dr.  George  Henry  Fox.) 


teum  and  perichondrium,  and  extends  rapidly  both  in  depth  and  in  surface. 
Because  of  rapid  interference  with  blood-supply,  it  is  prone  to  slough,  the 
destructive  process  extending  wide  of  the  original  infiltrate.  Bones  and  carti- 
lages rapidly  necrose;  there  may  be  complete  destruction  of  all  the  cartilages 
and  the  bones  immediately  surrounding  the  nasal  space.  Necrosis  of  the  cribri- 
form plate  of  the  ethmoid  and  the  vomer,  by  taking  away  the  support  of  the 
nasal  bones,  allows  them  to  sink,  even  though  they  are  not  involved,  produc- 


SYPHILIS,  EYE,  EAR,  AND  RESPIRATORY  TRACT  799 

ing  the  so-called  saddle-back  nose.  This  is  more  commonly  due  to  associated 
necrosis  of  these  bones,  which  may  cause  complete  destruction  of  the  nose 
(Fig.  414).  From  extension  of  the  inflammation  the  ethmoid,  the  sphenoid, 
the  palatal  bone,  and  the  superior  maxillaries,  particularly  the  palatal,  nasal, 
and  alveolar  processes,  may  become  extensively  diseased. 

Diagnosis. — Gummata  and  gummatous  infiltrations,  involving  the  mucous 
membrane  of  the  nose,  are  characterized  by  ordinary  catarrhal  symptoms,  but 
differ  from  catarrh  in  the  fact  that  the  symptoms  are  constantly  referred  to 
the  same  diseased  area.  When  ulceration  becomes  deep,  involving  bones,  and 
before  this  in  hypertrophic  and  atrophic  rhinitis,  the  discharge  is  extremely 
offensive.  On  examination  the  destructive  process  is  often  found  to  be  wide- 
spread. Rounded  ulcers,  often  covered  with  thick  crusts,  mark  the  position 
where,  on  probing,  dead  bone  is  detected.  As  a  result  of  gummatous  involve- 
ment of  the  cribriform  plate,  lethal  inflammation  may  extend  to  the  meninges 
of  the  brain. 

In  the  early  stages,  where  there  is  simply  beginning  infiltration,  the  symp- 
toms and  lesions  are  so  like  those  of  chronic  catarrh  that  differential  diagnosis 
may  be  impossible.  The  history  of  the  case,  the  presence  of  possibly  specific 
lesions  resisting  the  ordinary  catarrhal  treatment,  and  finally  the  therapeutic 
test,  should  decide  this  question  before  destruction  of  bone  has  taken  place. 

When  perforation  of  the  septum  is  found  the  disease  is  almost  certainly 
sj'philitic,  though  tuberculous  lesions  may  produce  the  same  result. 

Syphilitic  involvement  of  the  olfactory  nerves,  commonly  due  to  pachy- 
meningitis of  the  base,  may  cause  anosmia. 

Treatment  consists  in  the  internal  administration  of  specifics  and  in  local 
cleanliness,  accomplished  by  antiseptic  and  stimulating  sprays  and  vapors. 
Exceptionally  the  bone-lesions  are  premature — i.e.,  they  complicate  secondary 
syphilis;  mercury  should  then  be  combined  with  the  iodides.  When  these 
lesions  are  distinctly  gummatous  in  type — and  under  such  circumstances  they 
are  nearly  always  late  tertiaries — the  iodides  form  the  basis  of  treatment, 
supplemented  by  mercury,  administered  preferably  by  inunctions.  WTien  dead 
bone  is  found  it  should  be  removed.  This  is  accomplished  under  ether  by 
means  of  the  finger  of  the  surgeon  aided  by  a  curette.  Bleeding  is  often  pro- 
fuse, but  is  readily  controlled  by  packing.  Following  this  the  whole  nasal 
cavity  must  be  cleaned  every  two  hours  with  sprays,  the  first  containing  hydro- 
gen peroxide  twenty-five  per  cent.,  the  second  dilute  solutions  of  thymol,  or 
Dobell's  solution,  or  other  disinfectants  and  antiseptics.  Insufflations  of  iodo- 
form and  iodol  may  be  serviceable  after  the  cleansing  spray.  W^hen  a  small  por- 
tion of  bone  is  necrotic  it  is  safe  to  wait  until  this  is  loosened  before  attempting 
to  remove  it,  at  the  same  time  pushing  the  constitutional  treatment. 

For  the  deformity  of  the  nose  which  sometimes  results  from  cicatricial 
contraction  following  extensive  necroses,  plastic  operations  of  various  kinds 
are  indicated.  Perhaps  the  most  satisfactory  from  a  cosmetic  standpoint  is 
the  insertion  of  an  artificial  bridge  of  bone  transplant.  Over  this  the  loosened 
skin  is  drawn  by  the  percutaneous  suture.  When  there  is  not  enough  healthy 
tissue  for  this  procedure,  the  fitting  on  of  an  artificial  nose  is  advisable. 

Syphilis  of  the  Larynx. — Secondary  lesions  of  the  larynx  appear  either 
as  a   general   erythema,   not   distinguishable  from   that   incident   to   cold   or 


800  GENITO-URINARY  SURGERY 

irritation,  or  as  mucous  patches,  which  are  mostly  found  on  the  aryepiglottic 
folds,  the  vocal  bands,  the  arytenoid  cartilages,  and  the  borders  of  the  epi- 
glottis. These  papules  are  sometimes  converted  into  superficial  erosions,  but 
usually  yield  quickly  to  constitutional  treatment,  leaving  no  trace,  save  at 
times  alteration  of  the  voice,  due  to  slight  thickening  of  the  mucous  membrane. 
Very  exceptionally  these  erosions  become  true  ulcers,  closely  simulating  those 
incident  to  gumma,  except  that  they  are  not  so  deep  nor  so  destructive. 

Tertiary  lesions  may  be  expressed  in  the  form  of  a  diffuse  gummatous 
infiltration  or  circumscribed  gumma. 

Diffuse  gummatous  infiltration  usually  attacks  the  epiglottis,  the  vocal 
cords,  and  the  posterior  wall  of  the  larynx.  The  mucous  membrane  is  red- 
dened and  thickened,  and  there  is  ill-defined,  widespread  infiltration  of  the 
surrounding  tissues.  If  ulceration  takes  place  it  is  generally  superficial,  though 
a  large  surface  may  be  involved. 

Symptoms. — The  symptoms  are  due  to  disturbance  of  function  incident 
to  infiltration.  There  is  little  or  no  pain.  Until  the  voice  becomes  husky  the 
patient's  attention  is  not  markedly  attracted  to  the  throat.  Very  slowly  pro- 
gressing ulceration  and  subsequent  cicatricial  contraction  produce  marked  alter- 
ations in  the  voice  and  may  obstruct  breathing.  Exceptionally  there  is  imme- 
diate total  aphonia,  followed  later  by  partial  stenosis,  with  the  constitutional 
symptoms  dependent  upon  dyspnoea. 

Diagnosis. — This  is  founded  upon  the  discovery  of  a  thickened,  often  super- 
ficially ulcerated  area,  without  associated  diseases  of  the  lungs,  and  with  a 
preceding  history  of  syphilis  and  often  other  manifestations  of  the  disease. 

Tuberculous  laryngitis,  the  only  affection  with  which  it  is  liable  to  be  con- 
founded, is  hardly  ever  encountered  in  conjunction  with  healthy  lungs. 

Circumscribed  gummata  involve  by  preference  the  epiglottis,  the  aryepi- 
glottic folds,  the  true  and  false  vocal  cords,  and  the  posterior  wall  of  the 
larynx.  At  first  they  appear  as  rounded  elevations,  the  mucous*  covering  of 
which  is  thickened;  later  softening  takes  place  and  deep  destructive  ulcera- 
tions are  formed,  ultimately  resulting  in  cicatricial  contraction,  which  seriously 
interferes  with  the  function  of  the  larynx.  During  the  ulcerating  stage  acute 
oedema  sometimes  develops  and  threatens  death  from  suffocation. 

Symptoms. — The  symptoms  are  much  the  same  as  those  of  diffuse  gum- 
matous infiltration,  except  that  the  discharge  is  more  profuse,  pain  and  tender- 
ness are  more  frequently  noted,  and  functional  disturbances  are  more  marked. 

Diagnosis. — This  is  founded  on  laryngeal  inflammation  associated  with 
nodules  and  ulcers  and  the  existence  of  a  history  and  other  signs  of  syphilis. 

In  distinguishing  these  lesions  from  those  of  tuberculosis  it  must  be  re- 
membered that  the  mucous  membrane  surrounding  syphilitic  ulcers  is  practi- 
cally normal  in  color  or  congested,  not  pale.  The  development  of  the  gum- 
matous infiltration  is  much  more  rapid,  and  the  therapeutic  test  will  usually 
lead  to  a  correct  diagnosis. 

The  syphilitic  ulcers  develop  quickly,  sometimes  in  a  few  days,  and  are 
surrounded  by  reddened,  oedematous  mucous  membrane.  The  ulcers  are  usually 
single,  and  involve  by  preference  the  upper  surface  of  the  epiglottis.  Tuber- 
culous lesions  require  months  for  development. 

The  distinction  between  gummatous  and  carcinomatous  infiltration  is  de- 


SYPHILIS,  EYE,  EAR,  AND  RESPIRATORY  TRACT 


801 


pendent  on  somewhat  the  same  difference  in  symptom.s,  though  occasionally 
microscopic  examination  of  an  excised  piece  will  be  necessary  before  the  true 
nature  of  the  case  can  be  determined.  The  differential  diagnosis  between 
syphilitic,  tuberculous,  and  cancerous  laryngitis  may  be  tabulated  as  follows: 


Syphilis. 

Development  of  ulcer 
acute,  occupying  only  a 
few  days. 

Considerable  irregular  in- 
flammatory or  oedema- 
tous  swelling. 

Epiglottis    affected,    if    at 

all,  on  upper  surface. 
Ulcer       solitary ;        rarely 

more  than  two. 
Proceeds    from    centre    to 

periphery,        or        from 

above  downward. 
Deep,   round,   or   oval. 
Diameter   of   one-third   to 

one  inch. 

No   cachexia. 

Treatment  usually  highly 
beneficial. 


Tubercle. 

Development  slow ;  fol- 
lows throat  symptoms 
after  several  months. 

Uniform,  pale  swelling, 
looking  like  an  infiltra- 
tion. 

Lower   surface. 

L'lcers  numerous. 

The  reverse  is  true. 


Generally    round. 

Diameter  much  stnaller 
(one-sixth  to  one- 
twelfth   inch). 

Phthisical    appearance. 

Treatment  has  but  very 
moderate  effect. 


Cancer. 

Intermediate  in  time ;  ap- 
pearance of  ulcers  in  a 
few    weeks. 

Nodular  excrescences  and 
acute  inflammation  of 
neighboring  mucous 

membrane. 

No  uniformity. 

Ulcer  solitary. 
Irregular  in  its  course. 


Irregular  in  shape. 
Diameter     much     smaller. 


Cachexia. 

Treatment  has  no  effect. 


ProgJtosis. — The  prognosis  of  gummatous  laryngitis  is  good  if  the  diag- 
nosis is  made  before  ulceration  has  had  time  to  effect  much  destruction  of 
tissue.  Resolution  under  specific  treatment  is  usually  prompt.  When  ulcera- 
tion is  extensive,  medicine  cannot  prevent  cicatricial  contraction  and  inter- 
ference with  function.  Under  these  circumstances,  when  dyspnoea  sets  in,  dila- 
tation of  the  strictured  portion,  often  supplemented  by  internal  laryngotomy 
and  the  wearing  of  an  intubation  tube,  or  tracheotomy,  will  be  necessary. 
In  addition  to  constitutional  treatment,  during  the  gummatous  stage  of  laryn- 
gitis the  lesion  should  be  touched  daily  with  iodine,  1  part,  potassium  iodide, 
10  parts,  glycerin,  100  parts;  it  having  been  previously  sprayed  and  cleaned 
by  antiseptic  solution  of  sublimate  1  to  2000.  Following  this  the  lesion  should 
be  dusted  with  iodol. 

Syphilis  of  the  Lungs. — ^The  trachea  and  bronchi  exhibit  the  lesions  of 
secondary  syphilis  in  the  form  of  mucous  patches,  which  in  the  few  observed 
cases  were  situated  on  the  posterior  walls  of  these  tubes  and  were  credited 
with  causing  an  obstinate  bronchitis,  yielding  only  to  specific  treatment. 

Gummatous  ulceration  of  the  trachea  and  bronchi  may  be  extensive  and 
superficial,  or  localized  and  deep.  It  is  commonly  placed  about  the  tracheal 
bifurcation,  and  may  cause  necrosis  of  one  or  more  rings,  these  in  some  few 
cases  having  been  coughed  up.  As  a  result  of  this  gummatous  ulceration,  the 
surrounding  organs  are  involved,  and  in  some  cases  the  oesophagus,  the  aorta, 
and  the  posterior  mediastinum  have  been  opened. 

If  the  respiratory  tubes  recover  from  the  inflammatory  process,  subsequent 
cicatricial  contraction  may  seriously  embarrass  respiration. 
51 


802  GENITO-URINARY  SURGERY 

Symptoms. — When  the  trachea  is  involved  in  addition  to  bronchoscopic 
findings  there  may  be  an  obstinate  cough,  with  expectoration  of  blood-stained 
sputa,  and  some  pain  and  tenderness  behind  the  sternum.  Large  tracheal 
rales  may  be  heard  on  auscultation.  When  the  bronchi  are  invaded  the 
prognosis  is  less  favorable  than  when  the  trachea  alone  is  attacked. 

Syphilis  may  attack  the  lungs  in  the  form  of  acute  catarrhal  or  croupous 
pneumonia,  somewhat  atypical  in  development,  symptomatology,  and  course, 
and  yielding  to  constitutional  treatment.     This  is  exceptional. 

Lung-symptoms  depending  on  syphilis  usually  develop  in  the  late  tertiary 
period.    Two  forms  of  lesions  are  observed: 

L  Diffuse  sclerosis,  characterized  by  bronchial  catarrh,  and  alternate  areas 
of  dulness  and  resonance. 

2.  Circumscribed  syphiHtic  gumma,  single  or  multiple,  usually  found  in 
the  middle  third  of  the  lungs,  but  occurring  also  at  the  apices.  The  patient 
may  exhibit  all  the  symptoms  of  typical  phthisis. 

A  form  of  chronic  pneumonia  characterized  by  diffuse  interstitial  infiltra- 
tion is  sometimes  found  in  hereditary  sj^hilis.  This  may  involve  the  entire 
lung  or  only  a  portion  of  it,  and  is  a  frequent  cause  of  death.  The  alveolar 
septa  are  so  thickened  by  the  specific  infiltrate  that  the  air-spaces  are  greatly 
encroached  upon,  the  lungs  cannot  expand,  and  the  pulmonary  circulation  is 
interfered  with. 

Gummatous  pulmonitis,  the  so-called  syphilitic  phthisis,  under  which  head 
are  included  the  diffuse  and  circumscribed  infiltrations,  develops  as  an  ordi- 
nary case  of  consumption,  except  that  the  constitutional  symptoms  are  at 
first  less  marked  and  the  course  is  less  rapid.  The  disease  begins  vidth  a 
cough,  slight  dyspnoea,  and  moderate  expectoration,  usually  without  fever. 
Percussion  dulness  and  bronchial  breathing  are  found  over  the  diseased  area. 
As  the  gummatous  infiltrate  increases,  the  expectoration  becomes  more  pro- 
fuse and  cavities  form.  Hectic  fever  is  developed,  and  all  the  characteristic 
symptoms  of  advanced  phthisis  appear. 

The  mid-portions  of  the  lungs  are,  according  to  the  majority  of  reports, 
most  frequently  affected. 

Diagnosis. — The  diagnosis,  usually  not  made,  might  be  indicated  by  a  posi- 
tive Wassermann  reaction,  a  syphilitic  history,  and  the  presence  of  other  mani- 
festations of  the  disease,  such  as  laryngeal  lesions,  perforation  of  the  palate, 
and  skin  cicatrices.  Tubercle  bacilli  are  not  found  in  the  expectoration; 
this  in  itself  is  suggestive  of  syphilis.  A  two  weeks'  treatment  by  arsenic 
and  inunctions  supplemented  by  iodide  internally  should  produce  marked 
improvement  of  symptoms  if  the  disease  is  syphilis.  Tuberculous  involvement 
is  made  worse  by  such  treatment. 

Primary  involvement  of  the  pleura,  with  characteristic  symptoms  of  pleurisy, 
is  almost  unknown.  There  may,  however,  be  a  pleuritis  with  effusion  secondary 
to  specific  pulmonary  involvement. 

Treatment. — This  is  practically  the  same  as  that  applicable  to  cases  of 
pulmonary  tuberculosis,  with  the  addition  of  arsenic,  inunctions  of  mercury, 
and  potassium  iodide  kept  below  the  limit  of  gastro-intestinal  upset  or  mani- 
festations of  the  toxic  action  of  the  drug. 


CHAPTER  XXXIX 

SYPHILIS  OF  THE  BONES  AND  JOINTS 

Lesions  of  the  bones  are  among  the  frequent  manifestations  of  constitu- 
tional syphihs. 

Symptoms  of  bone-involvement  may  appear  early,  at  times  even  before 
the  skin  eruptions.  Usually  the  lesions  are  distinctly  tertiary  in  type  and  in 
their  time  of  appearance. 

The  scrofulous  temperament,  cachexias  which  are  liable  to  be  attended 
with  alteration  of  the  bones,  as  gout  or  rheumatism,  and  particularly  trauma- 
tism, often  slight  and  unnoticed  in  itself,  are  causes  which  predispose  to  the 
development  of  specific  bone-lesions.  Superficially  placed  bones,  such  as  the 
frontal  bone,  clavicle,  sternum,  radius,  ulna,  and  tibia,  are  affected  most  fre- 
quently mainly  because  they  are  so  often  exposed  to  slight  injury. 

The  lesions  produced  by  syphilis  vary  from  a  simple  periostitis  to  the 
formation  of  typical  gummata.  These  lesions  may  undergo  resolution,  or 
may  be  followed  by  exostosis,  eburnation,  caries,  and  necrosis.  They  may  be 
classed  under  the  following  heads: 

1.  Simple  osteoperiostitis. 

2.  Rarefying  ostitis. 

3.  Gummatous  osteoperiostitis. 

Osteoperiostitis,  also  called  precocious  periostitis,  may  develop  at  the 
time  of  skin  eruption,  or  even  before  this,  within  three  weeks  of  the  appear- 
ance of  a  chancre;  commonly  it  occurs  either  in  the  first  three  months  of  the 
disease  or  in  the  tertiary  period.  Pathologically  it  does  not  differ  from  osteo- 
periostitis due  to  non-specific  causes.  The  periosteum  becomes  hyperaemic,  and 
there  is  cellular  infiltration  of  its  deeper  layers  and  the  contiguous  portion  of 
the  bone.  The  bones  of  the  cranium,  the  tibia,  the  ribs,  the  sternum,  and 
the  clavicle  are  most  frequently  affected. 

Symptoms. — These  are  subacute  in  type.  On  examination  there  is  de- 
tected a  tender,  slightly  elastic  swelling,  evidently  growing  from  the  bone;  the 
skin  may  be  slightly  puffed  and  reddened,  and  the  pain  is  often  intense,  espe- 
cially at  night.  Usually  the  symptoms  yield  promptly  to  treatment,  the  swell- 
ing disappearing  without  leaving  a  trace  of  its  seat.  Sometimes  in  place  of 
resolution,  osteogenesis  takes  place,  and  bony  nodules  permanently  mark  the 
seat  of  trouble;  or  from  a  deposit  of  bone  on  the  walls  of  the  Haversian  canals 
the  osseous  tissue  may  become  unduly  dense,  resulting  in  eburnation. 

Rarefying  Ostitis. — When  the  inflammation  is  more  intense  the  cellular 
infiltrate  not  only  invades  the  lower  layer  of  the  periosteum  and  the  bone 
surface,  but  penetrates  along  the  course  of  the  Haversian  canals,  eroding  their 
bony  walls,  and  substituting  for  the  solid  osseous  substance  soft  embryonal 
tissue.  If  the  process  is  acute  the  normal  tissue  may  entirely  disappear  at 
the  seat  of  infiltration,  and  suppuration  may  take  place,  resulting  in  the  forma- 
tion of  a  bone  abscess  and  in  caries  or  necrosis. 

803 


S04 


GENITO-URINARY  SURGERY 


Usually  the  embryonal  tissue  gradually  encroaches  upon  the  bone-tissue,  till 
the  latter  much  resembles  sponge  in  shape  and  structure,  or  the  infiltrate  may 
become  organized,  obliterating  the  lumen  of  the  Haversian  canals,  and  fiUing 
the  medullary  canal  with  a  hard,  heavy,  compact,  osseous  tissue,  producing 
eburnation.  Caries  and  necrosis  may  also  occur  at  the  seat  of  eburnation 
as  a  result  of  ischaemia  incident  to  obhteration  of  the  Haversian  canals. 

Gummatous  Periostitis,  Ostitis,  and  Osteomyelitis. — While  the  simple 
and  rarefying  forms  of  osteoperiostitis  offer  no  clinical  or  pathological  features 
which  will  distinguish  them  from  similar  lesions  due  to  causes  other  than  syph- 


FiG.    415. — Gummatous    osteomyelitis    of    femur. 

ilis,  except  their  tendency  toward  bone  formation,  the  formation  of  gummata  in 
bone  points  definitely  to  syphilis.  The  lesions  appear  as  tumors  varying  in  size 
and  exhibiting  a  tendency  towards  centric  caseous  degeneration.  These  tumors 
are  formed  by  rarefying  ostitis  in  which  the  superabundant  subperiosteal  or 
medullary  embryonal  tissue  undergoes  the  changes  and  arrangement  character- 
istic of  the  gumma.  These  gummata  may  develop  in  the  deeper  layer  of  the 
periosteum,  in  the  bone-substance,  or  in  the  medullary  cavity.  They  are  usu- 
ally multiple,  and  may  invade  any  portion  of  the  skeleton. 

The  gummatous  involvement  of  the  bone  may  be  circumscribed  or  diffuse. 

Circumscribed  gummatous  osteomyelitis  appears  in  long  bones  in  the 
form  of  nodules  developing  in  the  medullary  canal.     Centrally  they  are  found 


SYPHILIS  OF  THE  BONES  AND  JOINTS 


805 


to  be  softened  or  undergoing  caseous  degeneration,  while  peripherally  they 
are  surrounded  by  a  sclerosed  area.  In  the  spongy  tissue  the  gummata  are 
imperfectly  encapsulated  by  the  same  fibrous  formation   (Fig.  415). 

Diffuse  Gummatous  Osteomyelitis. — The  lesions  of  this  form  of  bone 
syphilis  more  frequently  involve  the  soft  parts  in  gummatous  changes,  re- 
sulting in  the  formation  of  fistulae  leading  to  the  bone.  The  periosteum  is 
always  infiltrated;  the  bone  is  greatly  deformed  and  appears  worm-eaten.  Its 
surface  is  irregular,  studded  with  osteophytes,  perforated  with  small  or  large 
openings,  and  exceedingly  unequal  (Figs.  416  and  417),    Some  of  these  per- 


FiG.    416. — Skull    showing    the   results    of    grxunmatous 
osteoperiosteitis 

f orations  are  small,  others  as  large  as  two-fifths  of  an  inch  in  diameter.  On 
section  of  the  bone  hyperostosis  and  eburnation  will  be  found  in  some  regions, 
and  marked  rarefaction  in  others,  the  whole  bone  being  considerably  increased 
in  volume  (Fig.  418).  The  new  ossification  is  exceedingly  irregular  in  posi- 
tion and  consistence.  The  bone  is  often  so  brittle  that  the  least  effort  is 
enough  to  break  it.  Indeed,  the  irregular  eburnation  and  rarefaction  are  con- 
sidered by  Oilier  as  characteristic  of  the  osseous  lesions  of  syphilis. 

All  these  lesions  are  marked  by  indolence  of  inflammatory  symptoms  and 
by  rarity  of  extensive  necrosis.  As  a  result  of  intense  rarefying  periosteitis, 
particularly  where  this  is  diffuse,  there  is  always  destruction  of  bone-tissue. 
When  the  flat  bones  are  attacked,  lesions  may  be  circular  or  semicircular 


806 


GENITO-URINARY  SURGERY 


in  arrangement.  This  circinate  arrangement  is  rarely  observed  in  the  long 
bones.  Nearly  always  associated  with  the  destruction  of  tissue  there  is  noticed 
peripherally  a  formative  ostitis.  This  follows  the  course  of  destructive  action, 
resulting  in  overgrowth  and  eburnation. 

Necrosis  is  usually  a  feature.  Most  of  the  sequestra  are  found  to  be  ebur- 
nated.  Sometimes  the  bone  seems  almost  normal  in  structure,  often  being  cut 
off  from  its  nutrition  by  a  peripheral  gummatous  infiltration,  which  obliterates 
its  vessels  and  deprives  it  of  nutrition. 

Tegumentary  lesions  may  cause  bone  necrosis  by  extension  of  infiltration 
to  the  periosteum;  thus  the  nasal  bones  and  cartilages  are  most  frequently 
destroyed. 

The  more  chronic  forms  resulting  in  osteosclerosis  and  osteoporosis  are 


Fig.   417. — Vault  of  the  cranium  exhibiting  the  results  of 
gummatous  osteoperiosteitis 

attended  with  few  subjective  symptoms,  perhaps  nothing  more  than  boring 
nocturnal  pains,  which  are  usually  considered  as  rheumatic. 

Symptoms. — The  symptoms  of  gummatous  bone-involvement  are,  when  the 
lesion  is  circumscribed  and  begins  in  the  periosteum,  fairly  characteristic. 
There  is  formed  a  painless,  sometimes  excessively  painful,  tumor  of  slow  growth, 
which  softens  centrally  and  exhibits  a  peripheral  ring  of  dense  induration. 
Several  bones  are  often  invaded  at  the  same  time,  or  the  lesion  is  multiple, 
and  there  is  commonly  a  syphilitic  history  to  be  elicited.  The  diagnosis  between 
syphilitic  and  tuberculous  ostitis  is  based  in  the  main  upon  X-ray  findings, 
which  show  always  in  S5^hilis  marked  osteogenesis,  little  if  any  in  tubercu- 
losis. Tuberculous  lesions  of  the  bones  of  the  skull  and  of  the  shafts  of  the 
long  bones  are  rare;   syphilitic  involvement  is  common, 

Tuberculosis  has  a  special  predilection  for  the  epiphyses  of  the  young. 


SYPHILIS  OF  THE  BONES  AND  JOINTS 


807 


OsTEOSYPHiLOSis  OF  THE  Cranium. — Precocious  osteoperiostitis  and  ostitis, 
and  tertiary  exostoses,  are  frequently  observed  in  the  bones  of  the  cranium. 
The  exostoses  may  develop  upon  both  the  external  and  the  internal  tables. 
In  the  latter  case  they  are  of  moment  from  the  meningitis  which  they  excite. 
Rarefying  ostitis  and  gummatous  periostitis  are  often  observed,  with  consecu- 
tive eburnation,  as  are  also  circumscribed  gummata.  These  lesions  may  de- 
velop in  the  diploe,  or  in  the  pericranium,  or  in  the  dura,  involving  the  bone 
subsequently. 

When  placed  upon  the  cranium  the  gummatous  lesions  exhibit  a  circinate 
arrangement  and  cause  but  scanty  suppuration.     Frequently  small  and  multi- 


ple. 418.— Rarefying  gummatous  osteitis  of  ulna.   (Skiagram  by  Dr.  H.  K.  Pancoast.) 


pie  aummata  will  involve  a  considerable  extent  of  surface,  circumscnbmg  a 
lar-e  portion  of  the  internal  or  the  external  table,  which  eburnates,  becomes 
ischemic,  and  necroses.  When  the  pericranium  alone  is  involved,  the  ex- 
ternal table  is  destroved.  \^Tien  the  syphiloma  is  located  m  the  dura  mater, 
it  is  the  internal  table  alone  that  is  involved.  WTien  syphilomata  of  the  pen- 
cranium  and  the  dura  are  developed  on  opposite  portions  of  the  same  bone, 
complete  perforation  may  result.  This  may  also  follow  from  a  gumma  de- 
veloping in  the  diploe. 

Gummata  of  the  dura  mater  are  accompanied  by  a  circumscribed  pachy- 
meninaitis  which  is  sometimes  hemorrhagic.  Frequently  these  gummata  de- 
veloping upon  the  dura  are  followed  by  no  external  signs,  though  sometimes 
they  mav  consecutivelv  involve  the  soft  tissues  and  suppurate.  Dry  canes 
resulting'  in  the  formation  of  stellar  cicatrices,  sometimes  in  complete  perfora- 
tion, due  to  gummatous  infiltration  followed  by  absoi-ption.  is  comparatively 


808  GENITO-URINARY  SURGERY 

rare.  Usually  the  soft  parts  are  involved,  and  there  is  the  ordinary  form  of 
caries  or  necrosis. 

The  external  exostoses  of  the  cranial  bones  are  similar  to  those  observed 
in  the  other  parts  of  the  body.  Exostoses  encroaching  upon  the  brain  are 
interesting  from  the  fact  that  they  sometimes  occasion  focal  symptoms. 

These  projections  are  noticed  over  the  frontal,  parietal,  temporal,  and  occip- 
ital lobes. 

Some  instances  of  general  hyperostosis  due  to  syphilis  have  been  observed. 

The  bones  of  the  face,  particularly  those  of  the  nose  (turbinals,  cartilagin- 
ous, and  bony  septum,  alar  cartilages,  less  often  the  nasal  bones),  are  favorite 
seats  of  gummatous  infiltration.  The  affection  may  develop  primarily  in  the 
bone,  or  may  be  secondary  to  ulcerating  or  tubercular  gumma  of  the » soft 
parts.  The  superior  maxilla  frequently  exhibits  these  lesions,  particularly 
the  alveolus,  the  palatal  plate,  and  the  nasal  process.  The  disease  usually  goes 
on  to  necrosis. 

The  vertebrae  exhibit  the  ordinary  bone-lesions  of  syphilis,  but  are  per- 
haps especially  apt  to  suffer  from  circumscribed  gummata.  Caries  and  necrosis 
may  develop,  followed  by  spinal  deformity — syphilitic  Pott's  disease.  As  in 
tuberculous  disease  of  the  spine,  the  cord  and  its  envelopes,  the  spinal  nerves, 
and  the  surrounding  parts  may  be  affected  either  by  pressure  of  the  infiltrate 
or  by  involvement  in  the  inflammatory  process. 

Osteosyphilosis  of  the  foramina  may  from  the  swelling  cause  pain,  anal- 
gesia, or  paralysis,  due  to  pressure  upon  the  spinal  nerves. 

The  Tibia  is  more  often  involved  in  tertiary  syphilis  than  any  other  of 
the  long  bones.     Caries,  necrosis,  and  exostoses  are  frequently  noted. 

The  Phalanges. — Syphilitic  dactylitis  appears  in  the  form  of  a  gummatous 
deposit,  which  may  involve  the  subcutaneous  connective  tissue  of  the  fingers 
and  toes,  together  with  the  periosteum  and  bones  of  these  parts.  This  involve- 
ment appears  in  a  superficial  and  in  a  deep  form. 

In  the  superficial  form  there  is  gummatous  infiltration  of  the  subcutaneous 
tissues,  which  subsequently  involves. the  ligaments  surrounding  the  joints.  If 
the  toes  are  affected  they  generally  exhibit  the  lesions  through  their  entire 
length.  In  the  fingers  the  hardening  and  enlargement  are  commonly  limited  ta 
a  single  phalanx. 

Syphilitic  dactylitis  is  characterized  by  a  slow,  painless  swelling,  most 
marked  on  the  dorsal  aspect  of  the  finger,  and  rarely  extending  farther  up 
than  the  metacarpo-phalangeal  articulation.  There  is  some  discoloration  of  the 
affected  area;  the  region  of  the  joint  becomes  swollen,  and  from  softening  of 
its  ligaments  there  results  preternatural  mobility.  These  enlargements  exhibit 
an  ultimate  tendency  towards  softening  and  ulceration. 

This  form  of  the  disease  develops  as  a  late  secondary  or  distinctly  tertiary- 
manifestation. 

The  deep  form  appears  as  a  specific  osteomyelitis  and  periostitis.  It  usually 
involves  an  entire  carpus  or  tarsus,  though  it  may  be  confined  to  the  opposing 
extremities  of  two  phalanges.  The  proximal  phalanges  of  the  fingers  are 
commonly  attacked,  often  several  at  one  time.  When  the  metacarpal  bones 
are  also  involved,  these  are  generally  of  the  thumb  and  the  index  finger. 

This  form  occurs  late  in  the  disease,  from  five  to  fifteen  years  after  the 
appearance  of  the  chancre.    It  is  chiefly  limited  to  the  bones  and  the  periosteum^ 


SYPHILIS  OF  THE  BONES  AND  JOINTS  809 

the  integument  being  seldom  involved.  Sometimes,  however,  when  the  process 
is  rapid  and  extensive,  ulceration,  caries,  and  necrosis  result.  As  the  joint 
becomes  involved,  the  cartilages  are  eroded  and  crepitus  may  be  detected. 
From  infiltration  of  the  ligaments  and  capsule  the  function  of  the  joint  may 
be  seriously  interfered  with,  the  latter  being  sometimes  rendered  too  loose. 
or,  again,  from  extensive  swelling  motion  being  almost  entirely  prevented.  Even 
when  ulceration  does  not  take  place  there  may  be  shortening  or  deformity 
of  the  bone  consequent  upon  dry  caries  or  interstitial  absorption. 

Syphilitic  dactylitis  occurs  much  more  frequently  in  hereditary  than  in 
acquired  syphilis.     The  fingers  are  less  frequently  affected  than  the  toes. 

SYPHILIS   OF  THE  JOINTS 

Arthralgia. — During  the  secondary  period  arthralgia  is  a  common  and 
early  manifestation  of  constitutional  disease.  This  sometimes  precedes  the 
eruption,  and  may  be  unaccompanied  by  fever.  Pain,  which  is  often  much 
worse  at  night,  is  the  only  symptom.    There  are  no  discoverable  lesions.    . 

Synovitis  may  develop  at  the  same  time;  usually  it  comes  later;  it  may 
be  either  polyarticular  or  monarticular.  It  may  appear  in  the  form  of  hydrar- 
throsis. 

Acute  polyarticular  synovitis  is  characterized  by  practically  the  same 
pathological  changes  that  are  observed  in  other  polyarticular  conditions.  In 
one  or  two  weeks,  especially  if  specific  treatment  is  instituted,  resolution  takes 
place. 

Acute  monarticular  synovitis  exhibits  the  same  symptoms  as  the  poly- 
articular form  of  the  affection,  except  that  the  disease  is  strictly  confined  to 
one  joint,  usually  the  knee,  is  intensified,  and  is  much  more  liable  to  become 
chronic.  Moreover,  it  yields  slowly  to  treatment.  This  monarticular  form  of 
trouble  sometimes  follows  the  polyarticular  involvement,  resolution  taking  place 
in  all  but  a  single  joint.  Pathological  changes  are  in  this  case  more  pro- 
nounced. 

Hydrarthrosis,  or  chronic  hypertrophic  synovitis,  pursues  practically  the 
same  course  as  chronic  synovitis  from  other  causes.  There  is  thickening.  The 
synovial  membrane  is  tufted,  and  there  is  a  gummatous  infiltration  extending 
even  to  the  articular  cartilages  and  the  ligaments.  There  is  a  marked  effusion 
into  the  joint,  and  ultimately  it  may  be  rendered  useless,  either  from  limitation 
of  motion  or  from  absolute  fixation.  When  there  is  extensive  involvement 
of  the  cartilages  and  bones,  osteophytes  may  form,  resulting  in  partial  or 
complete  bony  ankylosis. 

Gummatous  arthritis,  a  late  manifestation  of  S3^hilis,  is  characterized 
by  the  development  of  gummata,  primarily  of  the  ligaments  or  articular  carti- 
lages, and  is  generally  accompanied  by  the  synovial  changes  encountered  in 
hydrops  articuli — i.e.,  thickening  and  tufting  of  the  synovial  membrane.  In 
certain  cases  the  nodular  gummatous  infiltration  may  be  distinctly  felt  in 
the  general  swelling  involving  the  joint. 

The  amount  of  serous  effusion  varies  greatly.  Either  resolution  may  take 
place  or  the  joint-cavity  may  open  and  suppurate.  The  joints  may  be  second- 
arily involved  from  gummatous  or  ulcerative  processes  of  the  overl3ang  parts, 
or  of  the  bones  entering  into  their  formation. 


810  GENITO-URINARY  SURGERY 

The  joints  most  frequently  involved  are  the  sterno-clavicular  and  the  knee; 
the  elbow,  the  wrist,  and  the  ankle  follow  next  in  order  of  frequency. 

Symptoms. — Gummatous  synovitis  when  it  develops  first  in  the  capsular 
synovial  membrane  causes  few  symptoms  aside  from  an  apparently  movable, 
circumscribed  tumor.  Exceptionally  the  whole  joint  becomes  quickly  swollen, 
and  there  are  limitation  of  motion  and  rapid  muscular  atrophy.  Ultimately 
there  are  more  or  less  fixation  and  permanent  deformity.  If  the  bone  is 
involved  in  the  gummatous  process  the  swelling  is  usually  more  marked,  the 
articular  extremity  of  the  involved  bone  becoming  distinctly  thickened;  mus- 
cular atrophy  is  extremely  rapid.  The  subjective  symptoms  are  often  in  their 
mildness  out  of  proportion  to  the  apparent  severity  of  the  lesions.  With  a 
greatly  swollen  and  inflamed  knee-joint  the  patient  may  be  able  to  walk 
with  comparative  ease  and  comfort.  If,  however,  the  cartilage  has  been  eroded 
there  may  be  total  disability,  and  in  any  event  there  is  likely  to  be  more  or 
less  pain,  particularly  severe  at  night. 

Diagnosis. — The  comparative  rarity  of  syphilitic  joint  affections  and  their 
similarity  to  tuberculous  involvement  often  lead  to  an  incorrect  diagnosis  and 
to  the  needless  loss  or  sacrifice  of  an  articulation.  This  is  particularly  true 
of  the  knee-joint.  Syphilitic  synovitis  presents  no  clinical  feature  in  its  course 
by  which  it  can  be  distinguished  from  other  forms  of  synovitis.  The  tuber- 
culin and  Wassermann  tests  should  be  employed  in  all  doubtful  cases.  In  the 
acute  forms  of  the  affection  the  absence  of  heart-lesions  and  failure  of  anti- 
rheumatic remedies  may  suggest  the  true  nature  of  the  synovitis. 

Chronic  syphilitic  hydrarthrosis,  in  the  absence  of  a  history  or  symptoms 
of  s)^hilis,  cannot  be  distinguished  from  tuberculous  synovitis  except  by  the 
Wassermann  and  therapeutic  tests.  Under  the  use  of  mercury  and  potassium 
iodide  enormous  effusions  may  slowly  disappear. 

Gummatous  arthritis  and  synovitis  can  be  positively  diagnosed  only  by  the 
evidence  offered  by  other  lesions  of  syphilis,  such  as  ulcerating  gummata  of 
the  skin.  Tuberculous  arthritis  differs  from  the  gummatous  in  the  fact  that 
it  is  often,  though  not  necessarily,  associated  with  characteristic  tuberculous 
lesions  elsewhere,  that  it  is  more  prone  to  ulcerate  and  open  externally,  and 
that  it  produces  more  rapid  and  extensive  destruction  of  the  bone. 

Prognosis. — The  prognosis  of  syphilitic  joint  disease  is  comparatively 
good  when  the  affection  develops  early  in  the  course  of  S3qDhins  and  is  recog- 
nized and  promptly  treated.  Later,  atrophic  changes,  or  those  due  to  infec- 
tion, produce  permanent  deformity  and  disability.  The  synovitis  yields  readily 
to  specific  treatment.  Arthritis,  even  though  cartilages  and  joints  are  exten- 
sively involved  and  there  are  contraction  and  deformity,  is  also  curable  by 
constitutional  treatment,  reinforced  in  cases  characterized  by  abscess  formation 
and  bone  necrosis  by  sequestrectomy,  partial  arthrectomy,  or  other  surgical 
procedure.  Even  when  total  arthrectomy  is  required,  provided  the  nature  of 
the  disease  has  been  recognized,  the  prognosis  is  better  than  if  the  joint  disease 
has  been  due  to  causes  other  than  syphilis. 

Treatment. — The  treatment  of  syphilitic  joints  consists  in  rest  secured  by 
fixation  and  traction,  supplemented  by  passive  movements  and  massage  at  a 
later  stage,  Bier's  congestion  and  helium  therapy  to  stimulate  local  circulation, 
and  the  administration  of  specific  treatment,  usually  supplemented  by  the  iodides. 


CHAPTER  XL 

SYPHILIS    OF  THE   MUSCLES,  CARDIOVASCULAR  AND 
LYMPHATIC  SYSTEMS 

SYPHILIS  OF  THE  MUSCLES 

Acute  irritative  myositis  develops  very  exceptionally  during  the  first 
year  of  secondary  syphilis.  The  symptoms  are  identical  with  those  of  a  mus- 
cular rheumatism  which  is  slow  in  onset  and  somewhat  chronic  in  type. 

There  is  dull  pain,  aggravated  by  pressure  or  motion.  Sometimes  this  is 
exceedingly  severe.  The  biceps  and  triceps  are  most  frequently  involved. 
They  sometimes  exhibit  irritative  contraction,  seriously  interfering  with  the 
motion  of  the  part,  and  controlled  only  by  constitutional  treatment. 

The  symptoms  yield  readily  to  vigorous  constitutional  treatment. 

Tertiary  syphilis  may  attack  the  muscles  in  the  form  of — 

1.  Chronic  interstitial  myositis. 

2.  Gummatous  myositis. 

Chronic  interstitial  myositis  begins  as  a  cellular  infiltration  of  the 
muscular  fibres;  the  infiltrate  subsequently  becomes  organized  into  connective 
tissue,  resulting  in  muscular  contractures  and  atrophy. 

The  pathological  changes  are  marked  in  the  bellies  of  the  muscles;  the 
anal  sphincter  and  the  humeral  biceps  are  most  frequently  involved,  though 
contractions  of  the  sterno-cleido-mastoid,  pectoralis  major,  rectus  abdominals, 
masse ter,  and  many  other  muscles  have  been  noted. 

Symptoms. — There  are,  in  addition  to  severe  pain,  slight  tenderness,  limi- 
tation of  motion,  and  diffuse  swelling.  As  the  disease  progresses  the  muscle 
atrophies  and  shortens. 

Diagnosis. — Chronic  syphilitic  myositis  when  unaccompanied  by  other  and 
more  characteristic  signs  of  syphilis  may  imitate  toxic  myositis  from  other 
causes.  The  syphilitic  affection  is  unattended  by  constitutional  symptoms  or 
joint-involvement.  It  develops  without  apparent  cause.  It  is  slowly  and  per- 
sistently progressive,  and  is  shortly  accompanied  by  contracture.  Moreover. 
it  exhibits  marked  predilection  for  certain  muscles.  The  therapeutic  test  should 
positively  decide  the  matter. 

Gummatous  myositis  differs  from  the  interstitial  infiltration  only  in  the 
facts  that  it  is  circumscribed,  forms  a  distinct  tumor,  often  involves  neighbor- 
ing parts,  and  exhibits  a  tendency  to  degenerate,  soften,  and  discharge. 

Gummata  of  muscle  are  usually  late  manifestations  of  syphilis;  in  the 
malignant  forms  of  the  disease  these  may  develop  in  the  first  year,  and  under 
such  circumstances  are  apt  to  suppurate. 

Symptoms. — Usually  gummata  develop  as  painless,  slowly  growing  tumors, 
seated  at  the  point  of  insertion  of  the  muscle  or  in  its  belly,  movable  with 
the  latter,  but  fixed  when  it  is  strongly  contracted;  exceptionally,  when  in- 
filtration is  rapid,  there  may  be  great  pain  and  tenderness.    The  tumor  rarely 

811 


812  GENITO-URINARY  SURGERY 

reaches  the  size  of  a  man's  fist.  It  may  simulate  maHgnant  disease  so  closely 
that  the  therapeutic  test  alone  will  enable  a  diagnosis  to  be  made.  These 
gummata  are  absorbed,  soften,  or  become  converted  into  dense  fibroid  masses. 
The  trapezius,  pectoralis  major,  gluteus,  biceps,  and  lingual  muscles  are  oftenest 
affected. 

Prognosis. — Diffuse  interstitial  myositis  and  muscular  gummata  if  treated 
early  yield  completely  to  iodides  and  mercury;  later,  when  the  muscular  fibres 
have  atrophied  and  cicatricial  contractions  have  occurred,  constitutional  treat- 
ment is  unavailing,  except  to  prevent  further  extension  of  the  syphilitic  process. 

Syphilitic  tenosynovitis  may  appear  in  the  acute,  the  chronic,  or  the 
gummatous  form. 

Acute  Tenosynovitis  may  develop  in  the  early  secondary  period,  and  is 
characterized  by  effusion,  tenderness,  and  swelling  along  the  course  of  the 
tendon.  It  subsides  quickly  under  specific  treatment.  Several  tendons  may 
be  affected  simultaneously,  and  there  may  be  great  pain  and  tenderness,  and 
an  associated  syphilitic  synovitis  with  fever.  The  affection  is  more  common 
in  women  than  in  men. 

Chronic  Tenosynovitis. — Rarely  chronic  tenosynovitis  develops,  charac- 
terized by  effusion  and  crepitation  along  the  course  of  the  tendon.  It  is 
accompanied  by  some  thickening  of  the  sheath,  especially  observed  about  the 
extensor  tendons  of  the  fingers  and  toes  and  the  biceps  tendon. 

Chronic  syphilitic  tenosynovitis  is  usually  painless  and  yields  slowly  to  con- 
stitutional treatment.  It  presents  the  same  symptoms  as  the  non-specific  in- 
flammations of  the  tendon-sheaths. 

Gummatous  Tenosynovitis. — Gummata  sometimes  develop  in  the  sheath 
of  the  tendon.  These  are  painless,  and  are  either  round  or  spindle-shaped. 
Exceptionally  the  gumma  appears  in  the  form  of  a  diffuse  infiltration.  These 
gummata  subside  promptly  under  specific  treatment.  They  are  most  fre- 
quently found  on  the  tendo  Achilles  and  the  biceps  tendon.  The  diagnosis 
is  usually  facilitated  by  the  presence  of  gummata  elsewhere,  particularly  in 
the  muscles.  In  the  absence  of  these  or  other  signs  of  syphilis,  a  trial  of  specific 
treatment  should  be  instituted. 

Bursitis. — The  bursse  may  become  acutely  inflamed,  exhibiting  the  char- 
acteristic symptoms  of  this  affection.    This  is  extremely  rare. 

Much  more  common,  though  still  rarely  encountered,  is  gummatous  bursitis, 
usually  observed  in  the  prepatellar  bursa,  appearing  in  the  form  of  a  nodular, 
painless,  fluctuating  swelling,  which  is  prone  to  soften  and  break  down. 

CARDIOVASCULAR   SYSTEM 

Heart. — Syphilitic  involvement  of  the  heart,  common,  but  often  unrecog- 
nized, appears  clinically  as  a  late  tertiary  manifestation,  according  to  Jullien, 
about  the  tenth  year  after  the  chancre,  though  its  lesions  are  found  much 
earlier.     All  three  layers  may  be  sites  of  the  disease. 

Myocarditis. — This,  the  common  form,  may  appear  as  a  chronic  diffuse 
infiltration  of  the  muscle  by  small  round  cells,  these  becoming  transformed  into 
fibrous  tissue,  so  that  the  myocardium  becomes  studded  with  areas  of  scar 
tissue,  varying  greatly  in  number  and  extent  in   different  cases,   frequently 


SYPHILIS  OF  THE  MUSCLES  813 

lying  directly  under  the  endocardium  or  pericardium,  or  gummata  may  form, 
varying  in  size  from  that  of  a  pea  to  that  of  a  pigeon's  egg,  chiefly  in  the 
walls  of  the  ventricles  or  in  the  interventricular  septum. 

Endocarditis. — The  syphilitic  form  of  this  disease  is  less  regularly  found 
on  the  valves  than  is  the  "rheumatic"  variety.  When  the  valves  are  attacked 
but  one  leaflet  may  suffer,  but  the  deformity  in  this  one  is  frequently  extreme. 
The  lesions  appear  as  thickened  plaques,  chiefly  on  the  walls  of  the  ventricles, 
fibrous  processes  running  from  them  deeply  into  the  underlying  muscle. 

Pericarditis  is  the  least  serious  of  the  syphilitic  lesions  of  the  heart.  Gum- 
mata are  rare;  the  usual  lesion  is  a  "milk-spot." 

Symptoms. — There  is  nothing  distinctive  of  syphilis  about  the  symptoma- 
tology of  these  lesions.  As  a  result  of  syphilitic  involvement  of  the  coronary 
arteries,  angina  and  the  myocardial  degeneration  incident  to  arterial  obstruc- 
tion are  fairly  frequent.  Since  the  vascular  degeneration  represents  a  terminal 
phase  of  the  infection,  this  being  true  also  of  peri-,  myo-,  and  endo-carditis, 
the  benefit  incident  to  specific  treatment  is  that  of  an  arrested,  and  not  of  a 
cured,  lesion.  Given  the  presence  of  other  lesions  of  syphilis,  the  history  of 
infection,  or  a  positive  Wassermann  test,  arsenic,  mercury,  and  the  iodides 
should  all  be  used. 

Prognosis. — This,  if  the  diagnosis  be  made  before  loss  of  compensation 
has  occurred,  is  distinctly  good  if  appropriate  treatment  be  given.  Many  cases 
get  practically  well;  a  few  die  of  rupture  of  a  cardiac  aneurism  or  of  angina; 
a  considerable  percentage  are  permanently  crippled  by  a  compensation  so  deli- 
cately balanced  that  they  can  stand  no  strain. 

The  cardiac  muscle  and  walls  of  the  aorta  are  the  favorite  lurking  places 
of  the  spirochaetes  in  "clinically  cured"  S3q)hilis.^ 

Arteries. — Any  one  or  all  of  the  arterial  coats  may  be  attacked.  In  the 
larger  vessels,  as  the  aorta,  the  disease  occurs  chiefly  in  patches,  and,  if  trauma 
be  excluded,  is  the  common  cause  of  aneurism.  In  the  smaller  arteries 
there  is  a  more  general  involvement,  leading  to  impaired  function,  ultimately 
to  local  death.  The  disease  does  not  equafly  affect  all  the  arteries  of  the 
body;  often  a  single  artery  or  group  of  arteries  is  involved. 

Symptoms  due  to  inadequate  blood  supply  are  those  of  similar  lesions 
from  other  causes.  When  the  vessels  of  the  brain  are  attacked  headache 
is  usually  the  first  symptom,  and  is  followed,  after  an  interval  of  weeks  or 
months,  by  epileptiform  attacks,  hebetude,  somnolence,  paralysis  with  or  with- 
out loss  of  consciousness;  finally,  coma  and  death.  The  symptoms  of  aneurism 
due  to  syphilis  depend  on  its  location.  Very  frequently  these  enlargements  are 
in  the  brain. 

Prognosis. — This  is  bad,  as  the  disease  is  usually  discovered  only  after 
extensive  structural  changes  have  been  produced. 

Treatment  is  the  same  as  for  other  tertiary  lesions,  except  that  iodides 
seem  to  be  particularly  indicated. 

Veins. — The  veins  rarely  exhibit  syphilitic  lesions.     Mauriac  instances  a 

^  Warthin :    Amer.  Jour.  Med.  Sciences,  1916,  clii,  508. 


814  GENITO-URINARY  SURGERY 

single  case  of  phlebitis  and  thrombosis  involving  several  vessels  and  occurring 
in  the  first  few  months  of  constitutional  syphilis. 

Phlebitis  in  secondary  syphilis  is  characterized  by  superficial  localization, 
multiplicity  of  veins  involved,  absence  of  embolism  or  serious  complications, 
and  recovery  under  specific  treatment. 

SYPHILIS  OF  THE  LYMPHATIC  SYSTEM 

While  primary  and  secondary  syphilis  produce  almost  invariably  marked 
effects  upon  the  lymphatic  nodes,  the  tertiary  form  of  the  disease  manifests 
itself  in  the  lymphatic  system  with  comparative  rarity. 

The  surface  nodes  are  much  more  rarely  involved  than  are  those  in  the 
neighborhood  of  viscera.  Of  the  deep  nodes,  postmortem  examinations  have 
shown  that  those  ordinarily  involved  are  the  bronchial,  the  pulmonary,  the 
mediastinal,  the  hepatic,  and  the  gastric. 

The  superficial  nodes  most  frequently  affected  are  those  in  the  epitrochlear, 
supraclavicular,  interclavicular,  cervical,  inguinal,  and  axillary  regions.  Pa- 
tients of  a  scrofulous  temperament  are  most  subject  to  these  enlargements. 

The  sclerous  and  gummatous  types  are  recognized.  Both  are  characterized 
by  primary  enlargement  incident  to  hypertrophy  and  cell  proliferation.  The 
tumor  formed  is  at  first  regular  in  outline,  smooth,  freely  movable  beneath 
the  skin,  and  indurated. 

Enlargement  of  a  single  node  is  rare.  Usually  a  whole  group  of  nodes  in 
one  region  of  the  body  is  involved.  The  tumors  vary  from  the  size  of  a 
cherry  to  that  of  a  man's  fist.  Usually  they  are  no  larger  than  a  hickory- 
nut.  Having  reached  this  stage,  the  tumors  may  slowly  undergo  resolution, 
taking  sometimes  months  or  even  years  to  accomplish  this;  or  exceptionally 
they  may  continue  to  enlarge,  becoming  soft,  adhering  to  the  skin,  and  ul- 
cerating, discharging  thick,  yellowish  pus  containing  shreds  of  necrotic  tissue. 
The  small  opening  at  first  formed  becomes  rapidly  large,  with  indurated,  ragged 
edges  surrounded  by  a  brownish-red  area  of  congestion. 

Exuberant  granulations  may  be  formed,  resulting  in  fungoid  growths. 

Specific  treatment  and  local  applications  cause  rapid  healing  of  these  ul- 
cers. There  remains  a  deep,  irregular,  pigmented  scar.  Occasionally  these 
ulcerating  syphilitic  lymphomata  become  phagedaenic. 

Diagnosis. — The  diagnosis  of  syphilitic  lymphomata  can  be  established  only 
by  careful  attention  to  the  history  of  the  case. 

Syphilitic  adenopathy  may  closely  simulate  tuberculous  adenitis.  The 
latter,  however,  is  usually  observed  in  infants,  or  at  least  during  early  adult 
life;  is  accompanied  by  other  evidences  of  a  tuberculous  diathesis;  attacks 
by  preference  the  cervical  and  submaxillary  nodes;  is  more  generalized,  and 
forms  larger  tumors;  commonly  exhibits  suppurative  periadenitis  with  forma- 
tion of  fistulous  tracts  not  distinctly  ulcerative  in  type;  does  not  become 
phagedaenic,  and  is  not  improved  by  specific  treatment.  Cancerous  adenopathy 
is  nearly  always  secondary.  The  tumor  grows  rapidly,  becomes  adherent 
to  surrounding  tissues,  ulcerates,  bleeds,  and  progresses  in  spite  of  treatment, 
producing  profound  cachexia. 


SYPHILIS  OF  THE  MUSCLES  815 

Prognosis. — Except  in  cases  where  general  ulcerating  lymphomata  become 
phagedaenic,  the  prognosis  is  exceedingly  good. 

Treatment. — Early  treatment  nearly  always  occasions  prompt  resolution. 
Both  potassium  iodide  and  mercury  should  be  given,  the  former  drug  in  full 
doses,  the  latter  internally,  and  locally  in  the  form  of  inunctions.  Even  when 
distinct  fluctuation  is  noted,  the  knife  may  not  be  necessary. 

Local  counter-irritation  and  the  administration  of  tonic  and  supporting 
treatment  will  hasten  resolution. 

Ulcerating  gummata  of  the  lymphatic  nodes  are  exceedingly  rare. 

The  treatment  is  that  of  other  tertiary  lesions. 

Syphilis  of  the  Spleen. — The  spleen,  closely  associated  as  it  is  with 
the  lymphatic  system  of  the  body,  is  frequently  affected  in  secondary  syphilis. 
There  is  a  distinct  enlargement,  usually  occurring  early,  but  sometimes  not 
for  several  months.  This  enlargement  is  not  followed  by  functional  troubles. 
There  is  nothing  to  call  the  patient's  attention  to  the  swelling,  and  it  is  rarely 
observed  unless  careful  search  is  made  for  it.  It  commonly  subsides  in  the 
course  of  a  few  weeks  or  months.  The  pathology  is  probably  the  same  d,s  that 
of  lymphatic  node  enlargement  of  secondary  syphilis. 

Tertiary  syphilis  may  produce  gummata  or  disseminated  or  localized  splen- 
itis, resulting  ultimately  in  partial  cirrhosis.  These  lesions  rarely  betray 
themselves  in  life  by  appreciable  symptoms.  It  is  only  as  the  result  of  post- 
mortem examination  that  their  existence  has  been  proved. 

They  may  be  suspected  when  physical  examination  shows  increase  in  the 
volume  and  consistence  of  the  spleen  and  when  deep  pressure  elicits  tender- 
ness. They  are  nearly  always  associated  with  similar  lesions  of  the  liver  and 
kidneys,  the  symptoms  of  which  completely  mask  splenitis. 


CHAPTER  XLI 

SYPHILIS  OF  THE  URO-GENITAL  SYSTEM  AND  MAM- 
MARY GLAND.     PROGNOSIS  OF  SYPHILIS 

SYPHILIS  OF  THE  URO-GENITAL   SYSTEM 

The  Kidneys. — The  kidneys  are  less  frequently  involved  in  the  lesions 
of  syphilis  than  are  the  genitals,  the  nervous  system,  or  the  liver.  They  may 
be  attacked  at  any  time  during  the  course  of  the  constitutional  disease,  the 
lesions  produced,  with  the  exception  of  gummata,  being  similar  to  those  which 
characterize  Bright's  disease  in  all  its  varieties. 

As  etiological  factors,  tuberculosis,  rheumatism,  gout,  and  alcoholism  are 
all  of  some  importance,  but  the  direct  exciting  cause  is  either  the  syphilitic 
virus  or  the  irritating  toxins  produced  by  it  in  the  body  and  excreted  through 
the  kidney  epithelium. 

Precocious  involvement  of  the  kidney  often  closely  follows  the  chancre, 
and  is  manifested  by  albuminuria,  usually  intermittent,  transitory,  and  moder- 
ate. The  total  quantity  of  urine  passed  daily  is  not  diminished,  nor  is  the 
specific  gravity  markedly  affected.  Microscopic  examination  at  most  may 
show  a  few  hyaline  casts.  This  albuminuria  develops  during  the  early  erup- 
tive period  and  subsides  promptly  under  treatment. 

Acute  syphilitic  parenchymatous  nephritis  is  characterized  by  lesions 
of  the  secreting  portion  of  the  organ,  producing  a  condition  analogous  to  that 
termed  large  white  kidney.  It  is  in  reality  a  parenchymatous  nephritis,  and 
differs  in  no  way  from  this  acute  or  subacute  form  of  Bright's  disease,  pre- 
senting the  same  complications  and   sometimes  terminating  fatally. 

Albuminuria,  granular,  epithelial  and  blood  casts,  lessened  secretion  of 
urine,  headache,  cedema,  and  other  symptoms  and  signs  of  acute  nephritis,  are 
present. 

The  diagnosis  is  founded  on  examination  of  the  urine,  the  acute  rapid  course 
of  the  affection,  the  associated  symptoms  and  signs  of  syphilis,  and  the  serologic 
and  therapeutic  tests. 

The  prognosis  is  favorable.  If  parenchymatous  nephritis  develops  in  late 
syphilis  and  is  associated  with  gummatous  infiltration  or  amyloid  degeneration 
of  other  viscera,  the  chances  of  cure  are  slight. 

The  more  profound  kidney  degenerations  characteristic  of  tertiary  syphilis, 
but  sometimes  occurring  in  the  late  secondary  period,  are  syphilitic  interstitial 
nephritis  and  gummatous  nephritis. 

Syphilitic  interstitial  nephritis  presents  the  same  pathology  and  lesions 
as  the  non-specific  form  of  the  disease.  The  symptoms  are  those  of  chronic 
Bright's  disease.  This  affection  is  more  grave  than  the  early  nephropathy. 
Indeed,  after  fibrous  tissue  has  once  fairly  developed,  complete  restoration  of 
the  kidney  to  its  normal  condition  is  impossible. 
816 


SYPHILIS  OF  THE  URO-GENITAL  SYSTEM  817 

There  is  first  a  cellular  infiltration  of  the  interstitial  stroma  and  of  the 
walls  of  the  vessels  and  perivascular  spaces.  This  infiltration  is  followed 
*by  sclerosis,  causing  atrophy  and  distortion  of  the  kidney,  particularly  notice- 
able in  the  cortex. 

The  symptoms  of  specific  interstitial  nephritis  are  the  same  as  those  of 
the  non-syphilitic  affection.  There  are  polyuria,  lowered  specific  gravity,  light 
straw  color  of  the  urine,  moderate  amount  of  albumen,  hyaline  and  granular 
casts,  increased  arterial  tension,  oedema,  headache,  asthma — indeed,  all  the 
well-known  symptoms  of  chronic  nephritis. 

The  diagnosis  as  to  the  specific  nature  of  the  affection  can  be  made  only 
by  finding  other  signs  or  symptoms  of  syphilis. 

The  prognosis  is  unfavorable. 

Gummatous  nephritis  is  rare.  The  individual  tumors  rarely  reach  large 
size.  Cornil  states  that  they  are  usually  multiple  and  are  found  chiefly  in  the 
cortical  substance  or  in  the  pyramids.  Interstitial  nephritis  is  nearly  always 
found  in  conjunction  with  them. 

Jaccoud  states  that  amyloid  degeneration  is  by  far  the  most  common 
manifestation  of  renal  syphilis.  Next  in  order  of  frequency  comes  granular 
atrophy;  third,  gumma. 

Wagner  describes  a  fourth  form,  which  he  calls  syphilitic  glomerulo-nephri- 
tis.    It  is  characterized  chiefly  by  hsematuria  and  ends  rapidly  in  uraemia. 

The  treatment  of  the  tertiary  kidney-lesions  is  conducted  on  the  same 
general  principles  as  would  apply  to  cases  of  chronic  Bright's  disease.  Arsenic 
and  mercury  must  be  administered  cautiously,  since  on  account  of  the  crippled 
condition  of  the  kidneys  they  are  extremely  liable  to  produce  toxic  symptoms. 
Potassium  iodide  if  tolerated  is  indicated  in  full  doses. 

Amyloid  degeneration  of  the  kidney  is  associated  with  one  or  more  of 
the  forms  of  syphilitic  nephritis.  Similar  degenerations  of  other  organs,  notably 
the  liver  and  the  spleen,  are  present,  and  occasion  profound  cachexia.  There 
are  no  characteristic  symptoms.    The  prognosis  is  bad. 

The  Ureters  and  the  Bladder. — Syphilitic  involvement  of  the  ureters 
so  far  as  symptoms  are  concerned  is  practically  unknown.  For  description  of 
syphilis  of  the  bladder,  see  p.  500. 

The  Epididymis  and  Testis 

The  syphilitic  virus  may  manifest  its  influence  upon  these  organs  either 
in  the  form  of  interstitial  inflammation  characterized  by  infiltration,  forma- 
tion of  connective  tissue,  and  atrophy,  or  in  that  of  gummata. 

As  clinically  observed,  syphilitic  lesion  of  the  testicle  appears  as  a  combina- 
tion of  the  forms  just  mentioned.  Both  epididymis  and  testis  may  be  involved, 
the  sclerous  and  gummatous  processes  going  hand  in  hand.  There  is  often 
an  accompanying  hydrocele.  The  lesions  may  be  observed  at  almost  any 
period  of  S3TDhilis  from  the  second  month  to  the  twentieth  year. 

SYPHttiTic  Epididymitis. — The  epididymis  when  involved  commonly  pre- 
sents an  indolent,  non-inflammatory,  indurated,  sharply  circumscribed  gumma, 
usually  of  the  right  globus  major.     Both  epididymes  may  be  affected  simul- 
taneously. 
52 


818  GENITO-URINARY  SURGERY 

Involvement  of  the  epididymis  without  implication  of  the  testis  is  rare. 
It  usually  develops  towards  the  end  of  the  secondary  period  of  the  disease. 
It  may  be  observed  at  any  time  during  the  secondary  eruptions,  and  at  this* 
period  undergoes  prompt  resolution  on  treatment,  since,  like  all  the  secondary 
lesions,  it  has  no  marked  tendency  towards  sclerosis  or  caseous  degeneration. 
When  it  develops  in  the  late  tertiary  period  it  corresponds  more  closely 
to  the  type  of  the  tertiary  lesions — that  is,  it  tends  to  break  down  and  ulcerate. 
This  occurrence  is  much  rarer,  however,  than  is  the  case  with  tuberculous 
lesions. 

The  enlargement  never  attains  great  size.  There  are  rarely  more  than  twO' 
nodules,  which  after  some  months  become  of  almost  cartilaginous  hardness. 
Exceptionally  there  may  be  a  number  of  small  nodules,  grouped  at  either  ex- 
tremity of  the  epididymis,  the  middle  portion  being  spared. 

Sometimes  this  affection  may  be  acute  in  its  onset  and  accompanied  by 
inflammatory  symptorns.  On  examination,  however,  a  rounded  tumor  at  the 
head  of  the  epididymis,  or  at  both  the  head  and  the  tail,  with  slightly  irregu- 
lar surface,  not  adherent  to  the  surrounding  tissues,  probably  circumscribed, 
and  without  fusion  into  the  tunica  vaginalis,  suggests  the  nature  of  the  lesion. 

Diagnosis. — The  diagnosis  of  syphiloma  of  the  epididymis  is  readily  made. 
The  absence  of  pain,  of  tenderness,  of  involvement  of  the  skin,  and  of  hydro- 
cele, together  with  the  infiltration  of  the  head  of  the  epididymis  rather  than 
of  the  tail,  would  exclude  gonorrhoeal  epididymitis. 

From  tuberculous  epididymitis  a  differential  diagnosis  based  upon  the  local 
symptoms  alone  may  be  difficult.  The  tuberculous  infiltrate  usually  involves 
the  caput  major,  producing  a  hard,  painless  induration  much  like  that  char- 
acteristic of  syphilis.  This  steadily  grows  larger,  presents  a  more  irregular 
and  nodulated  surface  than  does  the  syphiloma,  becomes  adherent  to  the 
skin  of  the  scrotum,  softens,  and  discharges,  forming  fistulse.  Tubercle  bacilli 
can  be  demonstrated  in  the  discharge  by  inoculation.  The  cord  becomes  in- 
durated, and  the  seminal  vesicles  and  prostate  are  usually  involved. 

Treatment. — ^Arsenic  and  mercury  are  indicated. 

Syphilitic  Orchitis. — After  the  heart,  larger  blood-vessels,  and  central 
nervous  system,  the  testicle  is  the  most  frequent  seat  of  tertiary  syphilis.  This 
organ  may  be  involved  in  the  early  months  of  the  secondary  period;  usually 
the  third  year  is  the  time  during  which  tertiary  symptoms  develop. 

The  affection  may  assume  the  sclerous  or  gummatous  form,  though  it  must 
always  be  recognized  that  these  two  processes  run  their  courses  side  by  side, 
and  that,  while  the  predominant  lesion  may  appear  as  a  cellular  infiltration 
of  the  albuginea  and  its  trabeculse  followed  by  cicatricial  contraction,  an  ex- 
amination of  the  diseased  testicle  shows  the  presence  of  small  or  large  gum- 
mata.  Per  contra,  even  though  the  affection  appears  to  be  entirely  gum- 
matous, it  is  always  associated  with  a  greater  or  less  degree  of  interstitial 
orchitis.  Whether  the  lesion  conforms  to  the  sclerous  or  the  gummatous 
type,  its  onset  is  insidious,  and  it  is  often  bilateral.  Its  course  is  exceed- 
ingly chronic,  and  it  terminates  in  (1)  resolution,  (2)  partial  or  complete 
atrophy,  or  (3)   destruction  by  ulceration. 

There  is  reason  for  believing  that  an  important  predisposing  cause  of  S5^h- 


SYPHILIS  OF  THE  URO-GENITAL  SYSTEM  819 

ilitic  sarcocele  is  gonorrhoea!  epididymitis;  traumatism  or  sexual  excesses  may 
also  lessen  local  resistance. 

Interstitial  or  sclerous  orchitis  is  the  common  form  of  syphiUtic  sarcocele. 
It  may  be  unilateral  or  bilateral.  It  is  usually  symptomless,  but  if  progres- 
sive may  be  accompanied  by  a  sense  of  weight  and  enlargement. 

The  testis  enlarges  uniformly  to  two  or  three  times  its  normal  bulk.  It 
forms  an  indurated,  non-sensitive  tumor.  The  epididymis  is  flattened  along 
its  posterior  border,  so  that  it  becomes  difficult  to  recognize  it  on  palpation. 
The  cord  is  rarely  involved.  The  surface  of  the  tumor  is  usually  smooth, 
though  it  may  be  nodular  or  ridged.    Testicular  sensation  on  pressure  is  lost. 

The  tumor  forms  slowly,  requiring  weeks  or  months  for  its  complete  evolu- 
tion. It  may  remain  stationary  for  months,  and  finally  subside,  leaving  an 
apparently  normal  testicle,  or,  in  place  of  resolution,  there  may  be  sclerogenesis 
and  complete  atrophy,  the  testicle  disappearing  and  the  vas  terminating  in  a 
fibrous  nodule. 

It  is  to  be  noted  that  even  though  both  testicles  are  involved  there  is  not 
necessarily  either  impotence  or  sterility,  since  the  infiltration  generally  spares 
some  of  the  interstitial  portion  of  the  gland. 

Acute  Syphilitic  Orchitis. — Exceptionally  this  sclerous  orchitis  may  de- 
part from  its  ordinary  type  and  the  symptoms  may  become  so  acute  as  entirely 
to  obscure  the  diagnosis.  In  this  form  of  the  disease  the  testicle  rapidly  swells, 
and  becomes  exceedingly  sensitive;  the  scrotum  is  reddened  and  cedematous, 
and  there  is  violent  and  constant  pain. 

Commonly  but  one  testicle  is  affected.  Acute  symptoms  last  but  a  few 
days.  The  inflammation  comes  on  without  exciting  cause,  rarely  presents 
symptoms  as  acute  as  those  of  an  inflammatory  orchitis,  and  is  distinguished 
from  gonorrhoeal  epididymitis  by  the  fact  that  the  testicle  is  primarily  en- 
larged and  presents  the  same  form  and  density  as  are  observed  in  the  ordinary 
syphilitic  sarcocele. 

As  a  rule,  the  tunica  vaginals  is  not  affected  in  syphilitic  sarcocele,  or  there 
is  but  moderate  serous  effusion.  This  is  sometimes  circumscribed,  and  may 
assume  a  pseudo-membranous  form.  Exceptionally  the  effusion  is  so  great  as 
to  prevent  palpation  of  the  testicle. 

Gummatous  Orchitis, — The  development  of  gummata  is  often  preceded 
by  the  sclerous  type  of  syphilis  of  the  testicle,  though  frequently  the  affection 
is  distinctly  gummatous  from  its  onset.  In  place  of  the  general  enlargement, 
or  rather  accompanying  this,  distinct  nodules,  ridges,  or  tumors  appear,  usually 
on  the  anterior  surface  of  the  testicle.  These  tumors  increase  in  size.  The 
tunica  vaginalis  becomes  adherent;  the  overlying  skin  of  the  scrotum  is  in- 
filtrated and  reddened,  and  finally  softening  and  ulceration  take  place,  with 
evacuation  of  broken-down  granulation-tissue  and  gummy  pus.  The  resulting 
punched-out  hollow  ulcer  has  dusky  indurated  borders,  and  communicates  with 
a  ragged,  irregular  cavity  containing  gray  unhealthy  granulations.  The  scar 
left  after  healing  is  adherent  to  the  testicle. 

At  times  the  granulation-tissue  slightly  proliferates,  and  forms  a  cauli- 
flower growth  projecting  externally  and  overlapping  the  seat  of  skin  perfora- 
tion;  this  is  known  as  a  benign  syphilitic  fungus. 


820  GENITO-URINARY  SURGERY 

There  are  two  varieties  of  syphilitic  fungus — the  superficial  and  the  deep. 
Both  originate  from  ulcerating  gummata.  The  superficial  fungus  starts  from 
gumma  of  the  scrotal  tissues  or  of  the  tunica  albuginea.  A  superficial  form 
which  is  almost  identical  and  is  more  common  is  due  to  tubercle. 

Parenchymatous  or  deep  fungus  is  usually  syphilitic.  It  arises  from  gumma 
of  the  testicle  proper.  The  granulations  grow  upward  through  the  albuginea 
and  the  tissues  of  the  scrotum.  At  times  portions  of  the  seminiferous  tubules 
will  be  found  in  the  discharge. 

Softening  and  ulceration  do  not  always  take  place.  As  in  the  case  of 
interstitial  orchitis,  gumma  may  spontaneously,  or  from  the  effect  of  treatment, 
undergo  resolution,  leaving  the  testicle  apparently  as  healthy  as  before  the 
attack,  or  crippled  and  deformed  by  cicatricial  contraction. 

According  to  Warthin,  "the  testes  of  all  old  syphilitics  show  a  more  or 
less  marked  degree  of  orchitis  syphilitica  fibrosa.  This  is  patchy  in  the  early 
cases,  but  tends  to  become  diffuse  and  may  involve  the  entire  organ.  The 
germinal  cells  are  vacuolated  m  the  early  stages,  and  there  is  a  gradual  loss 
of  spermatogenesis,  with  a  hyaline  thickening  of  the  basement  membrane  of 
the  tubules.  In  the  early  stages  spirochsetae  are  found  in  the  basement  mem- 
brane, and  there  are  slight  localized  areas  of  plasma-cell  infiltration.  In  the 
later  fibroid  stages  spirochaetae  are  not  present."  (Author's  abstract  of  paper 
read  at  meeting  of  American  Medical  Association,  1916.) 

Diagnosis. — The  diagnosis  of  syphilitic  sarcocele  in  its  typical  form  is  not 
difficult.  This  affection  commonly  develops  when  other  unmistakable  mani- 
festations of  syphilis  are  present.  The  tubercle  bacillus  and  the  gonococcus 
when  they  invade  the  testicle  attack  the  epididymis  primarily;  tubercle  com- 
monly invades  the  cord,  the  seminal  vesicles,  and  the  prostate.  Syphilis,  how- 
ever, hardly  ever  attacks  the  cord. 

Finally,  the  effect  of  constitutional  treatment  and  the  Wassermann  test 
will  be  found  valuable  in  clearing  the  diagnosis. 

Lymphadenoma  sometimes  almost  exactly  simulates  syphilitic  sarcocele.  It 
may  involve  one  or  both  testicles.  It  usually  spares  the  epididymis.  It  forms 
an  ovoid,  hard,  indolent,  uniform  swelling.  It  is,  however,  not  so  hard  as 
syphilitic  sarcocele.  Its  surface  is  always  smooth,  and  does  not  present  the 
slight  nodulations  or  ridges  which  are  often  present  in  the  syphilitic  testicle. 
Lymphadenoma  may  be  found  in  other  parts  of  the  body. 

Enchondromatous  growths  may  present  areas  of  unusual  hardness;  the 
growth  is  often  much  more  rapid  and  usually  attains  much  larger  dimensions 
than  in  syphilitic  sarcocele.  Local  and  reflex  pains  are  more  pronounced,  and 
specific  treatment  is  without  avail.  However,  it  is  often  necessary  to  wait 
before  diagnosis  can  be  established. 

In  the  acute  form  of  s^^philitic  sarcocele  diagnosis  must  be  made  by  ex- 
clusion; that  is,  when  the  possibility  of  traumatism,  of  gonorrhoeal  inflamma- 
tion, of  gout,  of  mumps,  of  tuberculosis,  of  continued  fevers,  of  violent  mus- 
cular effort,  has  been  excluded,  and  other  signs  of  syphilis  are  present,  the 
syphilitic  nature  of  the  affection  may  be  suspected. 

Syphilitic  fungus  of  the  testicle  may  be  confounded  with  ulcerating  carci- 
noma or  tuberculous   fungus.     The  ulcerating  carcinoma,  however,   involves 


SYPHILIS  OF  THE  URO-GENITAL  SYSTEM  821 

the  epididymis  and  cord,  affects  the  pelvic  and  post-peritoneal  lymphatic  glands^, 
forms  a  large  indolent  tumor,  gives  rise  to  much  pain,  is  attended  with  bleeding 
and  sloughing,  and  freely  secretes  ichorous  pus.  It  runs  a  rapid  course,  and 
is  attended  with  cachexia. 

The  tuberculous  fungus  differs  from  the  syphilitic  only  in  the  fact  that 
the  granulations  are  paler,  of  less  vitality,  and  not  attended  with  infiltration  of 
the  skin.     There  is  usually  cachexia. 

Prognosis. — The  prognosis  of  syphilis  of  the  testicle  is  good.  There  is 
rarely  deterioration  of  the  general  health,  or  abolition  of  the  sexual  powers. 
Although  the  disease  is  bilateral,  it  very  rarely  produces  complete  atrophy  or 
destruction.    • 

Even  after  loss  of  virility  and  fecundity,  proper  treatment  will  sometimes 
restore  both. 

Treatment. — Mercury,  arsenic,  and  the  iodides  are  indicated. 

Syphilis  of  the  Vasa  Deferentia,  Seminal  Vesicles,  Prostate, 
Urethra,  and  Erectile  Bodies  of  the  Penis. — There  have  been  reported 
a  few  cases  of  gumma  of  the  vas,  usually  in  connection  with  syphilitic  sarco- 
cele.  This  structure,  together  with  the  seminal  vesicles  and  the  prostate,  seems 
to  be  singularly  free  from  the  manifestations  of  tertiary  syphilis;  at  least, 
clinical  evidence  of  the  frequent  involvement  of  these  structures  is  wanting. 

Chancre  of  the  urethra  has  been  already  described  (see  p.  181). 

Secondary  syphilides,  particularly  the  mucous  patch,  have  been  observed 
on  the  urethral  surface.  These  occasion  a  slight  discharge,  which  is  sometimes 
mistaken  for  gonorrhoea  (see  p.  181). 

Gummatous  ulceration  is  exceedingly  rare,  or  at  least  is  not  often  recog- 
nized clinically.  Its  symptoms  are  usually  confounded  with  those  of  chronic 
urethritis  from  other  causes.  It  would  be  difficult  to  make  the  diagnosis  except 
from  urethroscopic  examination,  unless  induration  could  be  detected  by  external 
examination.     It  is  followed  by  dense  stricture  formation. 

The  primary  and  secondary  lesions  of  the  penis  have  been  already  described 
(see  p.  692  et  seq.). 

The  erectile  bodies  of  the  penis  may  exhibit  tertiary  manifestations  in  the 
form  of  diffuse  infiltration  or  of  gummata. 

Diffuse  infiltration  particularly  involves  the  meatus  and  the  frsenum,  to- 
gether with  the  mucous  membrane  of  the  prepuce  lying  to  either  side  of  this 
band.  Infiltration  may  be  either  superficial  or  deep,  and  may  involve  a  con- 
siderable portion  of  the  glans.     Ulceration  sometimes  follows. 

Gummata  are  usually  placed  on  the  proximal  third  of  the  cavernous  bodies. 
They  form  small  or  large,  ovoid,  indolent,  non-inflammatory,  cartilaginous 
tumors,  suggesting  during  their  early  development  the  presence  of  a  foreign 
body  in  the  tissues. 

Gummata  and  infiltrations  markedly  interfere  with  erection,  making  it  im- 
perfect anterior  to  the  seat  of  lesion  and  causing  bending  of  the  organ.  They 
are  obstinate  to  treatment,  and  are  scarcely  to  be  distinguished  from  the  plates 
of  induration  resulting  from  non-specific  cavernitis  or  fibroid  infiltrations. 

Diagnosis. — One  or  more  hard,  painless,  slowly  progressive  nodules,  grow- 
ing in  or  from  the  erectile  tissues  of  the  penis,  showing  no  tendency  to  ul- 


'822  GENITO-URINARY  SURGERY 

cerate,  and  giving  rise  to  no  symptoms  other  than  interference  with  erection, 
would  be  almost  pathognomonic  of  either  syphilis  or  non-specific  indurated 
plaques.  Between  these  two  affections  the  therapeutic  test  affords  the  only 
means  of  distinguishing. 

The  tertiary  manifestations,  which  closely  simulate  various  forms  of  chancre, 
are  much  more  chronic  in  their  course  than  the  primary  .lesion,  occasion  no 
adenopathy,  and  begin  as  infiltrations,  which  subsequently  ulcerate.  Moreover, 
there  is  a  preceding  history  of  secondary  syphihs,  or  possibly  the  evidence  of 
pre-existing  lesions  of  the  disease. 
Treatment. — As  for  all  tertiaries. 

Syphilis  of  the  Ovaries,  Uterus,  Vagina,  and  Vulva 

From  analogy  it  might  be  expected  that  syphilitic  involvement  of  the  ovary 
would  be  frequent.  CHnical  records,  however,  have  very  little  to  advance  in 
proof  of  this  theory.  It  is  probable  that  a  sclerous  and  a  gummatous  type 
of  ovaritis  occasionally  appear  as  manifestations  of  tertiary  syphilis.  This, 
however,  as  in  the  male,  occasions  no  subjective  symptoms,  follows  the  law 
of  tertiary  visceral  lesions  in  not  tending  to  ulcerate,  and  hence  escapes  notice. 
Autopsies  have  shown  that  such  lesions  occur,  and  a  few  clinical  observations 
prove,  at  least  so  far  as  the  therapeutic  test  is  concerned,  that  some  ovarian 
tumors  are  of  syphilitic  origin.  The  evidence  is  strongly  in  favor  of  the 
view  that  the  ovaries  are  far  less  subject  to  tertiary  disease  than  are  the 
testicles. 

The  Fallopian  tubes  are  involved  in  gummatous  lesions  even  more  rarely 
than  are  the  vasa  deferentia. 

The  uterus  of  syphilitic  women  is  frequently  attacked  by  endometritis, 
metritis,  perimetritis,  and  parametritis.  The  symptoms  and  complications  are 
the  same  as  the  homologous  non-specific  inflammations,  and  often  the  treat- 
ment is  as  tedious  and  unsatisfactory.  There  are  some  reported  cases  of 
uterine  tumor  disappearing  rapidly  under  the  use  of  potassium  iodide. 

The  vagina  is  very  exceptionally  the  seat  of  chancre.  Secondary  lesions, 
except  the  mucous  patch,  are  also  rare.  Tertiary  lesions  of  the  vagina, 
usually  appearing  in  the  form  of  a  diffuse  infiltration,  commonly  extend  from 
the  vulva  or  the  rectum,  in  the  latter  case  causing  recto-vaginal  fistulae.  Ex- 
ceptionally the  infiltrate  attacks  the  vagina  alone.  The  symptoms  are  those 
of  chronic  vaginitis,  with  marked  thickening,  particularly  of  the  posterior  wall, 
often  followed  by  ulceration  and  extensive  tissue-destruction. 

The  vulva  is  a  favorite  seat  of  syphilitic  lesions  in  all  stages  of  the  dis- 
ease. The  chancre,  secondary  syphilides,  gummata,  and  gummatous  infiltra- 
tion are  all  frequently  observed.  The  tertiary  lesions  are  prone  to  develop  in 
the  seats  of  primary  and  secondary  ulcerations.  They  are  usually  multiple,  bi- 
lateral, quickly  ulcerate  and  spread,  and  produce  a  thickening  and  warty  growth 
of  the  skin,  which  strongly  suggests  elephantiasis.  In  the  debilitated  and  un- 
cleanly phagedaena  develops,  with  extensive  tissue-destruction,  and,  in  case  of 
healing,  great  cicatricial  deformity. 


SYPHILIS  OF  THE  MAMMARY  GLAND  823 

Syphilis  of  the  Mammary  Gland 

Chancre  of  the  nipple  is  elsewhere  described  (see  p.  707). 

Secondary  Lesions. — Upon  the  overlying  and  overlapping  skin  papules 
are  particularly  liable  to  be  converted  into  mucous  patches  or  into  condylo- 
mata. 

Acute  irritative  mastitis  is  exceptionally  observed  in  both  men  and 
women  in  the  earliest  period  of  secondary  syphilis.  It  is  characterized  by  swell- 
ing accompanied  by  moderate  pain  and  tenderness;  it  subsides  quickly,  particu- 
larly under  specific  treatment. 

Gummatous  mastitis  may  be  diffuse  or  nodular. 

Diffuse  gummatous  mastitis  is  characterized  by  a  rather  dense  infiltra- 
tion involving  a  part  or  the  whole  of  the  breast.  Both  breasts  may  be  at- 
tacked together  or  consecutively.  More  commonly  one  side  is  involved.  If 
untreated,  atrophy  and  contractions  take  place,  ultimately  leaving  the  breast 
wasted  and  greatly  deformed. 

The  diagnosis  from  cancerous  infiltration  may  be  extremely  difficult,  but 
will  be  founded  upon  the  more  diffuse  form  of  the  syphilitic  infiltration,  the 
absence  of  lymphatic  involvement,  the  preceding  history  of  syphilis,  and  chiefly 
on  the  rapidity  with  which  symptoms  yield  to  constitutional  treatment. 

Gummatous  nodules  of  the  breast  develop  slowly,  occasion  little  or  no 
pain,  and  are  prone  to  ulcerate  and  discharge.  There  is  found  in  or  on  the 
breast  a  hard,  painless,  non-sensitive,  freely  moving  nodule,  which  in  a  few 
weeks  has  reached  the  size  of  an  egg,  softened,  become  adherent  to  the  skin, 
ulcerated,  and  discharged  a  turbid,  gummy  fluid. 

As  in  the  case  of  diffuse  infiltration,  these  gummata  may  lead  to  errors  in 
diagnosis.  Gummata  do  not  retract  the  nipple,  they  commonly  develop  be- 
fore the  age  of  cancer,  and  they  ulcerate  in  a  different  way  from  typical 
malignant  growths.  Usually  the  lymphatic  nodes  are  not  involved,  and  a 
history  or  signs  of  syphilis  are  obtainable. 

Specific  treatment  ordinarily  accomplishes  prompt  resolution  of  tertiary 
manifestations  in  the  breast,  and  is  the  main  test  upon  which  a  differential 
diagnosis  must  be  founded. 

The  Prognosis  of  SyphUis 

Syphilis  is  a  clinically  and  serologically  curable  disease.  This  cure  is 
accomplished  at  times  in  the  absence  of  all  treatment,  as  suggested  by  the 
countless  cases  of,  for  instance,  locomotor  ataxia,  without  history  of  primary 
or  secondary  lesions,  the  fair  inference  being  that  there  are  others  who  exhibit 
no  symptoms  through  life;  as  further  suggested  by  the  many  serologically  posi- 
tive cases  who  clinically  present  a  clean  health  record. 

In  such  cases  the  infection  is  either  destroyed  or  so  inhibited  that  it  be- 
comes a  pathological  factor  of  negligible  importance. 

If  treated  actively  in  its  primary  stage,  syphilis  is  probably  cured  in  the 
majority  of  cases,  though  absolute  proof  of  this  is  wanting.  The  same,  though 
to  a  less  extent,  is  true  of  the  secondary  stage.  The  manifestations  of  syphilis 
evidencing  an  infection  of  many  years'  standing,  excepting  those  of  the  cere- 
brospinal system  and  the  larger  blood-vessels,  may  usually  be  cured,  but  the 


824  GENITO-IJRINARY  SURGERY 

infection  probably  remains,  nor  is  a  negative  Wassermann  a  proof  of  its 
absence. 

Syphilis  predisposes  to  all  other  infections  and  to  cancer.  A  persistent 
infection  even  in  the  absence  of  recognized  clinical  manifestations  impairs 
health  and  shortens  life,  probably  by  its  deteriorating  influence  on  the  cardio- 
vascular system. 

As  to  the  prognosis  concerning  marriage,  a  man  well  treated  from  the  first 
and  with  a  persistent  negative  Wassermann  may  marry  in  two  years.  The 
same  is  true  of  a  woman.  A  man  well  treated  with  a  continued  positive  Was- 
sermann, but  no  clinical  symptoms,  may  marry  after  four  years.  A  woman 
with  a  continued  positive  Wassermann  should  not  marry  (see  also  p.  827). 

The  congenital  syphilitic  is  usually  vulnerable  and  short-lived.  If  his 
diagnosis  be  formulated  on  the  Wassermann  reaction  alone,  and  general  health 
be  maintained  in  infancy,  he  may  develop  tertiaries  later  on,  but  probably  will 
not  do  so. 


CHAPTER  XLII 

HEREDITARY  SYPHILIS 

Syphilis  is  transmitted  as  an  active,  contagious  disease.  It  reaches  the 
child  from  the  mother,  who  is  always  infected.  Simultaneous  impregnation 
and  infection  of  the  mother  are  incident  to  the  circumstance  that  the  spirochete 
habitually  infects  the  testicle,  and  that  the  infection  persists,  in  the  absence  of 
efficient  treatment,  probably  for  life.  The  spirochaete,  at  least  in  the  recognized 
form,  is  not  carried  by  the  spermatozoon,  for  obvious  mechanical  reasons. 

The  maternal  disease  may  be  due  (1)  to  infection  previous  to  con- 
ception, or  (2)  to  infection  occurring  at  this  time,  or  (3)  to  postconceptional 
infection. 

Descent  from  a  recently  syphilized  mother  is,  more  disastrous  in  its  effects 
than  from  one  in  the  late  stages  of  the  disease,  since  in  its  acute  course  the 
vitaHty  is  more  seriously  affected  and  the  transmitted  infection  is  at  its  maxi- 
mum, both  quantitatively  and  in  virulence. 

Moreover,  there  is  pronounced  placental  involvement,  profoundly  altering 
the  nutrition  of  the  infant.  If  these  inflammatory  and  vessel-occluding  proc- 
esses are  generally  diffused  over  the  placenta,  the  fcEtus,  of  course,  perishes. 
If  localized,  the  foetus  may  Hve  for  a  varying  length  of  time,  but  will  exhibit 
signs  of  malnutrition. 

Maternal  heredity,  most  potent  in  the  first  year  of  syphilis,  gradually  be- 
comes attenuated. 

Approximately  two-thirds  of  the  cases  in  which  syphilis  is  acquired  by  the 
mother  at  or  near  the  time  of  conception  perish  in  utero  or  shortly  after 
birth.  The  obvious  effects  upon  the  foetus  are  less  marked  in  proportion  to 
the  lateness  of  the  infection  in  regard  to  conception. 

Post-conceptional  syphilis — that  is,  infection  of  the  mother  during  the 
period  of  utero-gestation — may  be  transmitted  to  the  foetus  up  to  the  eighth 
month.  After  that  it  is  probable  that  the  child  will  escape,  although  cases 
are  reported  showing  that  chancre  acquired  in  a  woman  as  late  as  the  eighth 
month  has  been  followed  by  syphilis  of  the  child. 

Direct  infection  implies  inoculation  of  the  child  during  parturition  by 
the  contagious  discharges  of  secondary  vaginal  or  vulvar  lesions  of  the  mother. 
There  seems  to  be  no  reason  why  such  infection  should  not  exceptionally  take 
place  from  a  chancre  acquired  too  late  to  affect  the  child  in  utero. 

Syphilis  thus  conveyed  would  be  acquired,  not  inherited,  and  would  begin 
with  the  primary  sore.  Infection  from  secondaries  is  not  probable,  since,  if 
the  disease  has  reached  this  stage  in  the  mother,  the  child  is  already  syphilized, 
though  clinical  signs  may  be  absent. 

The  Period  of  Syphilitic  Heredity. — It  is  universally  conceded  that 
hereditary  syphilis  becomes  milder  in  type  and  less  likely  to  be  transmitted 
in  proportion  to  the  age  of  the  disease  of  the  parents.  Heredity  is  most 
potent  and  virulent  in  its  first  year.    There  is  a  rapid  attenuation  in  the  third 

825 


826  GENITO-URINARY  SURGERY 

year,  after  which  the  influence  of  the  disease  as  expressed  by  transmission  still 
diminishes,  but  at  a  slower  rate.  In  the  large  majority  of  cases  there  comes  a 
time  when  syphilis  is  no  longer  transmitted.  This  rule,  however,  is  subject  to 
exceptions.  Transmission  years  after  the  original  outbreak,  and  in  the  ab- 
sence of  all  signs  or  symptoms  of  the  disease  in  the  parents,  is  possible,  and  is 
more  common  than  is  generally  supposed.  Fournier  states  that  of  five  hundred 
and  sixty-two  cases  of  hereditary  syphilis,  in  sixty,  as  shown  by  clinical  signs, 
the  disease  was  transmitted  more  than  six  years  after  the  primary  infection. 
Cases  are  recorded  pointing  to  heredity  from  parents  in  the  fifteenth  and 
even  in  the  twentieth  year  of  syphilis.  The  Wassermann  test  shows  late  trans- 
mission in  the  latent  form  to  be  common. 

Treatment  exercises  upon  the  heredity  of  syphilis  a  more  powerful  effect 
than  time  alone;  an  active  specific  treatment  of  the  mother  reduces  the  birth 
mortality  to  almost  the  vanishing  point. 

The  type  of  parental  syphilis  does  not  necessarily  indicate  that  of  the 
inherited  disease.  Heredity  in  its  most  malignant  form  may  destroy  the  off- 
spring of  parents  suffering  from  mild  sjrphilis,  and,  conversely,  virulent  out- 
breaks in  the  parents  may  not  interfere  with  the  birth  of  children  either  but 
slightly  affected  or  apparently  healthy;  hence  it  is  unsafe  to  base  prediction  as 
to  the  type  of  inheritance  upon  the  type  of  disease  of  the  parents. 

CoNCEPTiONAL  SYPHILIS  is  that  acquired  by  the  healthy  mother  at  the 
time  of  conception.  There  is  no  primary  sore,  and  constitutional  symptoms 
may  be  entirely  wanting. 

Colles's  law  states  that  a  child  begotten  by  a  syphilitic  father  and  born 
of  an  apparently  healthy  mother  cannot  infect  her,  even  though  it  exhibit  ve- 
nereal ulcers  on  the  lips  and  tongue  and  in  suckling  cause  cracks  and  fissures 
in  the  mother's  nipple.  This  is  because  such  a  mother  is  already  syphilitic, 
even  though  she  show  no  clinical  symptoms. 

Conceptional  syphilis  may  appear  in  one  of  two  forms: 

1.  The  woman  may  shortly  after  conception  become  languid,  weak,  and 
emaciated,  complaining  of  headaches,  rheumatic  pains,  sleeplessness,  and  all 
the  symptoms  of  neurasthenia.  Miscarriage  occurs,  and  from  this  she  rallies 
very  slowly.  Subsequent  pregnancies  take  much  the  same  course,  the  mis- 
carriages coming  later  in  the  period  of  gestation.  Then  living  but  syphilitic,  and 
finally  healthy  children,  are  born. 

In  many  cases  undoubted  tertiary  symptoms  appear,  such  as  gumma  or 
periostitis.  All  these  symptoms  are  usually  rapidly  cured  by  specific  treat- 
ment. 

2.  The  woman  may  remain  apparently  well,  being  delivered  at  about  full 
term  of  a  child  which  either  at  birth  or  shortly  after  exhibits  the  characteristic 
lesions  of  hereditary  syphilis.  Experimental  inoculation  of  such  a  mother  with 
active  virus  will  not  produce  chancre.  She  is  immune  against  syphilis,  because 
she  has  the  disease  in  a  latent  form. 

Syphilis  and  Marriage. — The  prevalence  of  acquired  syphilis,  the  fre- 
quency with  which  it  is  transmitted,  in  unrecognized  form,  particularly  in 
regard  to  the  central  nervous  system,  the  severity  of  its  lesions,  and  its  crip- 
pling, deforming,  and  often  fatal  effects  when  it  is  inherited,  make  questions 


HEREDITARY  SYPHILIS  827 

pertaining  to  the  marriage  of  syphilitics  of  cardinal  importance.    Opinions  upon 
this  subject  should  be  clear  and  decided. 

From  what  already  has  been  said  it  is  obvious: 

1.  That  syphilis  is  most  apt  to  be  inherited  from  parents  who  at  the  time 
of  conception  are  in  their  first  year  of  the  disease. 

2.  That  the  tendency  towards  obvious  heredity  becomes  less  from  the  first 
to  the  third  year,  and  after  the  fourth  year  is  rarely  manifested. 

3.  That  time  in  conjunction  with  vigorous  continued  specific  treatment  so 
affects  the  tendency  to  heredity  that  after  the  fourth  year  it  is  usually  brought 
to  the  vanishing-point. 

4.  lliat  time  and  vigorous  treatment  combined  cannot  always  prevent  the 
transmission  of  syphilis  by  heredity.  The  instances  in  which  such  transmission 
has  occurred  after  four  years,  in  spite  of  active  treatment,  are,  however,  so 
few  that  they 'properly  can  be  rejected  in  considering  syphilis  and  marriage. 

The  logical  deduction  from  the  foregoing  summary  is  that  men  who  have 
syphilis  which  has  been  treated  carefully  for  two  to  four  years  can  marry  and 
will  have  healthy  children.  When  a  woman  is  syphilitic  it  would  be  safer 
to  avoid  conception  till  at  least  two  years  of  negative  Wassermanns  taken 
before  and  after  provocative  injections  of  small  doses  of  neosalvarsan  prove 
the  complete  latency  and  suggest  the  absolute  cure  of  the  infection.  Even  then 
such  a  woman  should  be  given  a  carefully  regulated  specific  treatment  during 
pregnancy  (seep.  890). 

Prognosis  of  Syphilitic  Heredity. — When  conception  takes  place  during 
the  early  secondary  period  of  syphilis  the  usual  result  is  abortion,  occurring 
from  the  first  to  the  fifth  or  sixth  month,  the  foetus  sometimes  exhibiting  the 
evidences  of  syphilis  in  the  shape  of  large  bullae  upon  the  palms  and  soles,  or 
other  characteristic  lesions,  but  quite  often  showing  nothing  distinctive.  Later, 
when  the  virulence  of  the  disease  of  the  parents  is  lessened  by  time,  either 
abortion  occurs  when  pregnancy  is  more  advanced,  or  live  children  are  brought 
into  the  world  which  at  birth  or  afterwards  show  signs  of  syphilis.  One-fourth 
of  these  die  within  the  first  six  months.  If  they  survive  that  period  the 
chances  for  life  are  slightly  in  their  favor,  but  the  chances  for  health  or  free- 
dom from  disease  are  overwhelmingly  against  them. 

Veeder  ^  reports  work  done  in  a  very  careful  manner,  as  follows: 

In  100  syphilitic  families  331  pregnancies  occurred,  which  resulted  as  fol- 
lows: 

Abortions    lOO  or  30.2  per  cent. 

Still-births 31  or     9.3  per  cent. 

Living-births 200  or  60.5  per  cent. 

This,  he  states,  is  a  prenatal  mortality  of  40  per  cent.,  against  a  normal 
mortality  in  the  same  social  strata  of  10  per  cent. 

''Considering  next  the  200  living  births:  At  the  time  the  data  were  col- 
lected 39  were  dead  and  161  alive,  but  12  of  the  161  died  during  the  course 
of  the  investigation.  Of  the  161  examined,  107  had  both  clinical  signs  of 
syphilis  and  a  positive  Wassermann;   5  were  clinically  positive  but  gave  nega- 

^  American  Journal   of  Medical  Sciences,   clii,    1916,    p.    522. 


328  GEXITO-URINARY  SURGERY 

tive  tests  (in  all  of  these  the  family  gave  a  history  of  syphilis) ;  16,  although 
negative  as  regards  dinical  manifestations,  gave  positive  reactions  .  .  . 
Thus  but  33  of  the  161  Uving  children  were  free  from  infection,  and  if  we 
attribute  the  deaths  occurring  before  term  to  syphilis  we  find  that  of  the  331 
pregnancies  in  100  syphilitic  familes  but  10  per  cent,  escaped  the  infection." 

When  the  question  of  prognosis  is  considered  in  regard  to  individual 
cases,  it  is  safe  to  predict  healthy  children  from  parents  who  at  the  time  of 
conception  are  past  the  fourth  year  of  syphilis  and  have  been  persistently 
treated.  Even  after  two  years  in  the  very  great  majority  of  cases  the  same 
outlook  is  justifiable.  In  the  first  year  prognosis  in  this  respect  must  be  more 
guarded;  but,  provided  the  mother  is  actively  treated  during  the  whole  period 
of  utero-gestation,  the  child  will  probably  be  born  healthy.  Exceptionally 
families  show  an  inveterate  tendency  to  heredity  little  influenced  by  time  and 
treatment.  Fournier  quotes  a  case  of  nineteen  pregnancies  each  resulting  in 
still-birth.  In  speaking  of  the  prophylaxis  of  hereditary  syphilis,  he  earnestly 
advises  that  a  man  who  has  been  infected  with  the  disease  should  be  forbidden 
marriage  till  time  and  treatment  have  accomplished  their  depurative  work, 
and  should  be  shown  without  mitigation  and  without  exaggeration  the  evils 
which  may  result  from  sexual  intercourse.  He  should  be  told  that  he  may 
infect  his  wife  directly  by  sexual  contact,  or  indirectly  through  the  medium 
of  the  foetus,  and  that,  if  she  fails  to  abort,  she  may  deliver  at  term  a  wizened, 
deformed,  blotchy  child, 'which  if  it  lives  may  show  the  stunted  development 
and  mental  incapacity  so  characteristic  of  hereditary  syphilis. 

When,  in  spite  of  warnings,  it  is  probable  that  sexual  life  is  continued,  the 
man  should  be  subjected  to  the  most  rapid  and  efficient  treatment  applicable. 
WTien  conception  has  taken  place  from  a  syphilitic  father,  the  mother  should 
receive  active  specific  treatment  during  the  whole  period  of  utero-gestation. 

HEREDITARY  SYPHILIS 

Hereditary  sj^hihs  differs  from  the  acquired  disease  in  being  constitutional 
from  the  first.  There  is  no  primary  stage — that  is,  there  is  no  chancre — nor 
in  the  course  of  its  development  can  the  manifestations  of  the  disease  be 
classed  under  periods.  They  may  correspond  in  type  to  secondary  or  tertiary 
lesions,  but  a  chronological  order  such  as  is  observed  in  acquired  syphilis  is 
wanting.  For  the  first  two  years  after  birth  secondary  and  tertiary  mani- 
festations appear  side  by  side.  Later,  at  about  the  time  of  puberty,  for  in- 
stance, if  lesions  appear,  they  belong  exclusively  to  the  tertiary  tj^e. 

The  local  expressions  of  hereditary  syphilis  correspond  closely  with  those 
already  described  as  characteristic  of  the  acquired  disease.  Thus,  the  S5^hilides 
are  pathologically  and  clinically  the  same,  and  this  is  true  of  visceral  involve- 
ments. The  main  point  of  difference  lies  in  the  profound  alteration  which 
S5Aphilis  in  its  hereditary  form  impresses  on  general  nutrition  and  development. 

In  a  certain  proportion  of  cases  the  characteristic  symptoms  of  hereditary 
syphilis  develop  at  birth  or  within  a  few  days  of  this  time.  Often  the  child 
remains  apparently  healthy  for  a  period  of  from  three  to  five  weeks,  manifesta- 
tions of  syphilis  then  appearing.  It  seems  well  substantiated  that  a  child  may 
show  no  symptoms  of  syphilis  for  several  years,  after  which  time  typical  ter- 


HEREDITARY  SYPHILIS  829 

tiary  lesions  may  develop.  In  many  of  these  cases  it  is  probable  that  the 
post-natal  lesions  were  so  few  and  slight  that  they  were  not  observed.  The 
form  of  the  disease  developing  more  than  three  years  after  birth  Fournier  called 
late  hereditary  syphilis. 

The  typically  syphilitic  child  is  at  birth  a  wasted,  wizened,  snuffling, 
feeble  creature,  with  a  weak,  hoarse  cry,  often  exhibiting  a  bullous  eruption 
of  the  skin.  It  has  been  blasted  ab  initio,  presenting  the  appearance  of  an 
advanced  stage  of  marasmus.  The  skin  is  harsh,  non-elastic,  and  gray  or  dirty 
yellow  in  color;  its  appendages — the  eyelashes,  eyebrows,  hair,  and  nails — also 
show  imperfect  or  perverted  development.  The  muscles  are  wasted.  The 
general  condition  is  well  expressed  by  the  term  atrophia  neonatorum,  which, 
though  it  may  result  from  a  number  of  prenatal  causes,  reaches  its  most  striking 
development  in  hereditary  syphilis.     Such  children  rarely  survive. 

When  the  influence  of  heredity  is  manifested  in  a  less  virulent  form  the 
child  may  be  born  properly  developed  and  apparently  well  nourished.  In  a  few 
weeks  lesions  of  the  skin,  mucous  membranes,  and  eyes  develop,  corresponding 
in  type  to  the  expressions  of  acquired  secondary  syphilis;  these  are  frequently 
associated  with  infiltrations  of  the  viscera  and  bones,  which  pathologically  belong 
to  tertiary  syphilis. 

Following  the  first  outbreak  there  is  an  intermediary  period,  lasting  a  year 
or  eighteen  months,  till  second  dentition,  till  puberty,  or  even  through  life. 
It  is  mainly  characterized  by  absence  of  symptoms.  The  general  expression 
of  the  syphilitic  diathesis  is  present,  marked  possibly  by  malnutrition,  retarded 
development,  wizened  face,  and  sunken  nose,  but  there  seems  to  be  little  ten- 
dency towards  renewed  outbreaks  of  secondary  lesions. 

The  tertiary  stage,  corresponding  to  the  tertiary  period  of  the  acquired 
disease,  manifests  itself  at  the  period  of  second  dentition,  about  the  time  of 
puberty,  or  towards  the  end  of  middle  life.  Its  lesions  may,  of  course,  develop 
at  any  time,  and  it  may  remain  latent  to  the  age  of  sixty   (Fournier). 

Skin  and  Mucous  Membrane  Lesions  of  Hereditary  Syphilis 
These  correspond  in  general  with  those  of  acquired  syphiHs,  but  are  more 
severe,  and  at  times  appear  in  the  form  of  diffuse  infiltrations.  They  vary 
somewhat  in  accordance  with  their  time  of  appearance  after  birth.  Those  which 
are  found  at  birth  are  most  pronounced.  Thus,  it  is  not  infrequent  to  observe 
a  pemphigus  so  extensive  that  a  greater  part  of  the  epidermis  is  involved  and 
is  shed  in  large  strips.  The  mucous  membrane  is  similarly  affected  at  the 
same  time.  The  lesion  at  birth  may  be  pustular  or  ulcerative  in  type.  In 
either  case  the  arrest  of  development,  hoarse  voice,  snuffles,  and  other  signs  of 
the  disease  are  usually  characteristic. 

When  the  child  is  born  apparently  healthy,  the  symptoms  not  developing 
for  some  weeks,  the  skin  eruption  is  commonly  erythematous  and  papular  in 
type,  at  least  primarily,  and  coincidently  with  its  appearance  snuffles,  sore 
mouth,  hoarse  voice,  and  general  emaciation  are  noted. 

Erythematous  (roseolar)  syphilides  differ  from  those  of  the  adult  only 
in  the  fact  that  the  epithelial  layer  of  the  skin  is  more  readily  macerated,  par- 
ticularly where  the  integument  is  creased  or  folded,  as  about  the  neck,  the 


830  GENITO-URINARY  SURGERY 

genitalia,  or  the  buttocks,  and  there  results  an  abraded  surface,  presenting 
the  appearance  of  a  mucous  patch. 

Syphihtic  roseola  is  apt  to  develop  about  the  second  or  third  week  after 
birth,  and  first  appears  on  the  body  in  the  form  of  small,  oval,  rounded,  or 
irregular  spots,  dull  red  in  color,  and  disappearing  upon  pressure. 

Sometimes  the  eruption  is  confluent,  covering  large  areas,  with  an  almost 
unbroken  sheet  of  dull  red  color. 

It  is  frequently  placed  about  the  genitalia  and  on  the  face,  thus  differing 
from  acquired  syphilitic  roseola. 

The  diagnosis  of  syphilitic  roseola  is  sometimes  difficult,  as  it  may  closely 
resemble  simple  erythema.  The  progress  of  the  disease  to  the  formation  of 
papules,  becoming  scaly  on  the  palms  and  soles,  and  the  prompt  yielding  to 
mercurial  treatment  are  characteristic  features  of  syphilis. 

Papular  Syphilides  and  Mucous  Patches. — These  lesions  arej  most 
marked  upon  the  buttocks,  palms,  soles,  and  face,  but  may  be  diffused  over 
the  entire  body.  The  small  papules  are  situated  in  groups,  sometimes  rounded, 
more  often  irregular  in  shape,  and  tend  to  coalesce  and  form  broad,  flat  papules. 
In  the  comers  of  the  mouth  they  are  converted  into  painful,  bleeding  fissures, 
which  on  healing  leave  permanent  scars.  These  scars  serve  a  useful  diagnostic 
purpose  in  later  life.  Exfoliation  is  most  marked  in  the  plantar  and  palmar 
papular  S5^hilides,  which  when  confluent  may  cause  the  epidermis  to  be  shed 
in  large  strips,  exposing  a  thick,  raw-ham-colored  infiltration  of  the  true  skin. 
This  corresponds  in  t3^pe  to  the  plantar  and  palmar  psoriasis  of  acquired 
syphilis,  and  may  be  complicated  by  painful  cracks  or  fissures. 

Papules  when  exposed  to  heat  and  moisture,  as  in  the  folds  of  the  buttocks, 
lose  their  surface  epithelium  by  maceration,  become  excoriated,  and  cause 
an  offensive  discharge.  These  mucous  patches  are  formed  most  commonly 
about  the  anus  or  the  angles  of  the  mouth.  Neumann  states  that  they  never 
exhibit  the  papillary  overgrowth  so  common  in  the  acquired  disease. 

The  papular  form  of  hereditary  syphilide  is  much  more  obstinate  to  treat- 
ment than  is  the  roseolar  form  of  the  disease. 

Vesicular  syphilide  appearing  in  the  form  of  small  discrete  blebs  is  usually 
associated  with  the  papular  and  papulo-pustular  lesions.  When  the  individual 
vesicles  are  large,  their  contents  soon  become  purulent.  The  small  vesicles  are 
grouped,  and  are  placed  on  indurated  papules.  The  eruption  is  rare,  and  is 
often  a  sign  of  severe  infection. 

Pustular  Syphilide. — The  lesions  of  this  S5^philoderm  commonly  succeed 
the  papular  eruption,  though  they  may  be  noted  at  birth  or  may  develop  as 
the  first  symptoms.  Frequently  they  do  not  appear  until  several  years  after 
the  first  outbreak. 

The  pustules  vary  in  number,  size,  and  depth  in  accordance  with  the  severity 
of  the  disease.  They  are  most  frequently  seen  on  the  buttocks,  thighs,  scalp, 
face,  hands,  and  soles,  and  are  said  to  indicate  the  probability  of  the  late 
tertiary  outbreaks. 

As  in  the  adult,  the  pustular  eruption  may  take  the  form  of  acne,  impetigo, 
or  ecthyma.  Syphilitic  impetigo  is  most  frequent  on  the  face  and  scalp.  The 
axillary  and  inguinal  regions  are  also  seats  of  preference.    Distinct,  often  deep, 


HEREDITARY  SYPHILIS  831 

ulceration  beneath  the  crusts,  and  copper-colored  infiltration  of  the  periphery 
of  the  lesion,  differentiate  the  syphilitic  aft'ection  from  simple  impetigo.  Syphi- 
litic ecthyma  attacks  the  buttocks  and  thighs  by  preference,  forming  large,  fiat, 
infiltrated  pustules,  the  thick  crusts  of  which  conceal  deep  ulcers. 

Nearly  all  these  pustular  lesions  leave  permanent  scars;  they  may  be  com- 
plicated by  cellulitis  and  gangrene,  leading  to  wide-spread  destruction  of  the 
skin. 

Bullous  Syphilide. — The  bullous  syphiloderm  or  pemphigus  commonly 
appears  on  the  soles,  palms,  fingers,  toes,  or  limbs.  The  eruption  consists  of 
blebs  more  or  less  irregularly  distended  with  liquid,  which  may  be  clear,  cloudy, 
or  bloody.  It  begins  as  dark,  circumscribed  infiltrates,  from  which  the  epidermis 
is  shortly  raised  in  the  form  of  blebs. 

These  blebs  are  circular  or  oval  in  shape,  sometimes  irregular,  are  seated  on 
inflamed  reddish  skin,  are  surrounded  by  a  slight  areola,  and  have  a  tendency 
to  become  confluent  and  spread.  When  a  child  exhibits  such  an  eruption  at 
birth  or  immediately  after,  the  presence  of  syphilis  should  be  strongly  sus- 
pected, and  will  be  quite  certain  if,  in  conjunction  with  the  pemphigus,  the 
general  cutaneous  surface  is  yellow  or  muddy  in  hue,  is  without  elasticity  or 
softness,  owing  to  the  absence  of  subcutaneous  fat,  and  is  for  the  same  reason  so 
furrowed  and  wrinkled  about  the  face  that  the  child  presents  an  appearance  of 
senility,  and  if  there  are  also  other  syphilitic  skin-lesions  and  the  child  has 
snuffles  and  a  hoarse  cry. 

The  appearance  of  pemphigus  is  ominous,  denoting  an  extreme  degree  of 
poisoning  by  the  syphilitic  virus. 

When  the  bullae  of  pem.phigus  are  filled  with  serum  deeply  stained  with  blood, 
there  may  be  an  associated  hemorrhagic  syphilis — that  is,  a  form  of  the  disease 
characterized  by  a  purpuric  eruption,  by  bleeding  from  the  mucous  membrane 
of  the  nose,  mouth,  and  gastro-intestinal  tract,  and  by  visceral  hemorrhages. 
The  bleeding  is  due  to  syphilitic  degeneration  of  the  blood-vessels,  especially  the 
veins  and  capillaries.  These  hemorrhages,  usually  multiple  and  slight,  are 
most  likely  to  occur  just  after  birth,  at  the  time  the  cord  is  tied.  Such  cases 
are  almost  invariably  fatal. 

Tubercular  and  Gummatous  Syphilides. — Tubercular  and  gummatous 
lesions  may  appear  at  any  age,  but  are  most  common  from  the  tenth  to  the 
twenty-ninth  year.  They  may  assume  the  dry  or  the  ulcerative  form,  and 
usually  exhibit  a  circular  or  circinate  grouping.  There  is  commonly  but  a 
single  group.  The  seats  of  predilection  are  the  face,  particularly  the  nose, 
and  the  anterior  surface  of  the  leg.  They  appear  in  the  form  of  painless, 
slowly  increasing,  raw-ham-colored  infiltrations,  which  commonly  ulcerate  and 
are  covered  with  thick  crusts.  These  ulcers  may  heal,  or  may  slowly  extend, 
forming  phagedsenic  or  serpiginous  lesions.  Non-ulcerating  infiltrations  absorb, 
leaving  atrophic  areas;  the  ulcerating  lesions  leave  deforming  cicatrices:  hence 
the  importance  of  early  recognition  and  prompt  treatment  of  these  sjqjhilides. 
They  closely  resemble  lupus,  particularly  when  the  face  is  attacked  (Fig.  419). 

Diagnosis. — The  differential  diagnosis  between  dry  tubercular  syphilide 
and  non-ulcerating  lupus  is  founded  upon  the  dusky-red  color  of  the  syphilide 
and  the  firm  induration.  Tubercular  nodules  exhibit  a  more  translucent, 
yellowish  red,  and  are  more  yielding  to  pressure.    (Fournier.) 


832  GENITO-URINARY  SURGERY 

The  differential  diagnosis  between  the  ulcerating  syphiiides  and  lupus  (Four- 
nier)  is  founded  upon: 

1.  Areola. — The  areola  of  the  syphilide  is  dusky  red,  that  of  the  scrofulide 
is  lighter,  sometimes  of  a  bluish  tint. 

2.  Crusts. — Those  of  the  syphiiides  are  more  homogeneous,  more  compact, 
thicker,  and  harder  than  those  of  the  scrofulides.  They  are  more  frequently 
stratified  and  more  deeply  colored,  almost  black  or  greenish  black. 

3.  The  Borders  of  the  Lesion. — In  syphiiides  these  are  always  sharply 
marked,  elevated,  infiltrated,  punched  out,  and  adherent.  In  lupus  they  are 
less  distinctly  outlined,  are  fiat,  soft,  often  reduced  to  a  simple  ulcerating  cir- 


FiG.  419. — Tubercular  and  gummatous  ulceration  of  hereditary^ syphilis. 

cumference.    They  are  not  punched  out,  and  are  often  loose  and  undermined. 

4.  The  Base  of  the  Ulcer. — In  tertiary  syphilis  this  is  deep,  irregular, 
anfractuous,  and  exhibits  a  yellowish,  adherent,  semi-solid  covering,  representing 
the  necrosed  gummatous  infiltrate.  Lupus  shows  ulceration  more  on  a  level 
with  the  surrounding  surface,  with  cherry-red  granulations,  sometimes  exuber- 
ant, sometimes  presenting  a  smooth  glistening  surface. 

5.  Configuration  of  the  Lesion. — Often,  but  not  invariably,  the  syphilitic 
lesions  form  a  complete  circle,  a  portion  of  a  circle,  or  serpentine  undulations. 
The  ulcers  of  lupus  are  more  irregular. 

It  is  not,  however,  on  these  minor  points  of  difference  that  the  diagnosis 
will  in  the  main  be  founded,  but  rather  upon  the  method  of  evolution,  the 
presence  or  absence  of  other  more  characteristic  lesions,  the  previous  history, 
careful  physical  examination  of  the  patient,  and  the  family  history. 

The  gummatous  syphilide  when  it  appears  as  a  diffuse  eruption  commonly 
undergoes  rapid  degeneration,  presenting  much  the  appearance  of  furunculosis. 


HEREDITARY  SYPHILIS 


833 


Onychia  of  a  dry  and  ulcerating  form,  and  alopecia,  are  observed  in  con- 
nection   with    the    skin-lesions   of   hereditary    syphilis. 

The  lesions  of  the  mucous  membrane  correspond  in  type  with  those 
observed  upon  the  skin;  thus,  when  pemphigus  is  noted,  large  or  small  raw 
surfaces  will  be  found  upon  the  mucous  Hning  of  the  throat  and  tongue;  when 
papular  and  papulo-pustular  eruptions  develop  on  the  body,  typical  mucous 
patches  will  be  found  in  the  mouth — that  is,  superficially  ulcerated  infiltrations 
covered  with  a  grayish  necrotic  membrane. 

Not  only  the  mucous  membrane  of  the  mouth  and  pharnyx  but  also  those 
of  the  nose,  ear,  and  larynx  are  liable  to  inflammation.  Indeed,  syphilitic 
coryza  is  one  of  the  most  characteristic  and  at  the  same  time  one  of  the  most 
important  of  the  early  symptoms  of  syphilis,  since  by  its  interference  with 

respiration  it  materially  hinders  the  proper  nutri- 
tion and  development  of  the  child.  This  condition 
of  the  nasal  mucous  membrane  is  shown  by  a  thin, 
watery,  irritating  discharge,  which  dries  in  crusts 
about  the  nasal  orifice;  beneath  these  crusts  are 
found  excoriations  and  ulcers.  The  catarrhal  swell- 
ing of  the  mucous  membrane  and  the  crusting 
produce  so  much  narrowing  of  the  air-way  that 
respiration  is  difficult  and  noisy,  the  latter  symptom 
giving  the  popular  name  "  snuffles  "  to  the  affection. 
Mucous  patches,  erosions,  and  ulcers  form  on  the 
lips,  particularly  at  the  angles  of  the  mouth,  and  on 
the  tongue,  the  gums,  the  palate,  and  the  pharnyx. 
Caries  and  necrosis  of  the  palate  and  of  the  nasal 
bones  frequently  complicate  these  ulcerations 
(syphilitic  ozsena). 

The  larynx  is  commonly  affected,  showing  the 
infiltrations,  erosions,  and  ulcerations  noted  on 
other  mucous  surfaces,  and  causing  the  characteristic  hoarse  voice.  Exception- 
ally infiltration  narrows  the  air-passage  to  the  point  of  producing  marked 
dyspnoea,  or  even  death. 

Later  in  the  course  of  the  disease — i.e.,  after  some  years  or  about  the  time 
of  puberty — typical  tertiary  manifestations  may  appear.  These  are  similar  to 
those  observed  in  the  adult.  They  are  characterized  by  deep  infiltrations, 
which  exhibit  a  tendency  to  break  down,  forming  ulcers,  which  are  accom- 
panied by  few  subjective  symptoms.  Their  seat  of  predilection  is  the  soft 
palate,  but  they  are  often  found  on  the  posterior  pharyngeal  wall,  the  anterior 
half-arches,  and  the  hard  palate.  The  mucous  membrane  of  the  nose  is  also 
affected,  and  the  ulceration  is  extremely  likely  to  extend  to  the  underlying 
bone,  producing  great  deformity  or  even  complete  destruction  of  the  facial 
portion  of  this  organ.  The  hard  palate  and  the  nasal  septum  are  usually 
perforated. 

Lupus  rarely  attacks  either  the  mucous  membrane  or  the  bones  of  the  nasal 
Dassas-es.  being  rather  sharply  confined  to  the  regions  of  the  anterior  nares. 
In  these  respects  it  differs  markedly  from  syphilis. 
53 


Fig.  420. — Syphilitic  dactylitis. 


834 


GENITO-URINARY  SURGERY 


When  tertiaty  infiltrations  attack  the  larynx,  destruction  of  cartilages  may 
ensue,  with  deforming  and  crippling  contractures,  or  the  bronchi  may  be  invaded, 
an  obstinate  form  of  bronchitis  resulting.  Spasm  or  cedema  of  the  glottis  may 
cause  sudden  death. 


Hereditary  Syphilis  Affecting  the  Eye 
Marginal   blepharitis  is  sometimes  encountered   as  a  result  of  hereditary 
syphilis,  appearing  in  the  form  of  small  irregular  ulcers,  usually  near  the  corners. 
The  treatment  is  cleansing  and  constitutional,  together  with  the  usual  applica- 
tions, particularly  the  ointment  of  calomel. 

The  lachrymal  apparatus  is  sometimes  involved  from  extension  of  inflam- 
mation dependent  on  caries  of  the  neighboring  bones. 

Interstitial  keratitis  is  the  most  characteristic  eye-lesion  of  hereditary 

syphilis.  This  commonly  begins  as  a  slight 
diffuse  haziness,  situated  in  the  cornea  itself, 
not  far  from  the  centre,  and  at  first  affecting 
but  one  eye;  usually  the  other  eye  is 
affected,  but  often  not  for  weeks  or  months. 
The  cloudy  deposits  lie  in  the  cornea,  and 
not  on  its  surface,  and  first  appear  as  dif- 
fuse spots;  these  later  become  confluent 
until  the  whole  cornea  is  opaque,  a  bare 
perception  of  light  remaining.  There  are 
usually  photophobia  and  slight  ciliary  injec- 
tion. The  disease  lasts  for  a  varying  period 
of  time,  weeks  or  m.onths;  then  the  cornea 
first  involved  begins  to  clear;  the  other 
cornea  follows  a  similar  course  in  time. 
In  most  instances  there  remains  a  slight 
permanent  haziness,  though  vision  is  good. 
In  severe  cases  the  whole  cornea  becomes 
congested,  blood-vessels  developing  in  its 
substance.  Cyclitis  and  retinitis  are  often 
associated  with  the  corneal  lesions,  and  in  bad  cases  there  may  be  secondary 
glaucoma  and  even  shrinkage  of  the  eyeball. 

Interstitial  keratitis  is  rarely  noticed  in  earl}^  infancy,  but  appears  usually 
between  the  eighth  and  the  fifteenth  year,  and  in  children  presenting  the  typical 
physiognomy  of  hereditary  S3^hilis. 

Biagncsis. — This  is  in  general  easy  to  make.  The  ground-glass  appear- 
ance in  the  early  stages,  and  the  dull  pink  or  salmon  color  if  the  vascular 
stage  is  reached,  are  characteristic.  In  syphilitic  keratitis  the  vessels  are  deep 
and  closely  interwoven,  producing  almost  the  effect  of  an  ecchymosis.  More- 
over, in  syphilis  the  disease  is  symmetrical,  there  is  a  tendency  to  spontaneous 
cure,  ulceration  hardly  ever  occurs,  and  there  is  but  slight  ciliary  congestion. 
The  grooves  left  by  the  new-formed  corneal  vessels  are  permanent,  and  their 
discovery  by  a  magnifying  glass  long  after  other  traces  of  keratitis  have  dis- 
appeared will  often  throw  light  on  an  obscure  case. 


Fig.  421. — Hereditary  syphilis.  Cicatrices 
of  fissured  lips  and  gummata  of  the  forehead 
and  orbit.     (De  Schweinitz.) 


HEREDITARY  SYPHILIS  835 

The  chief  diagnostic  point,  however,  is  the  association  of  this  form  of  kera- 
titis with  other  lesions  of  syphiUs. 

Iritis  appears  before  the  end  of  the  first  six  months.  It  is  later  than  the 
syphilodermata  and  of  rarer  occurrence,  but  it  is  extremely  important,  since,  if 
overlooked,  it  may  result  in  permanent  impairment  of  the  vision.  When  recog- 
nized it  constitutes  an  almost  pathognomonic  sign  of  syphilis. 

The  diagnosis  is  readily  made  when  attention  is  called  to  the  eye,  but  the 
affection  may  be  overlooked,  since  there  are  few  subjective  symptoms. 

When  the  disease  is  fairly  developed  the  pupil  is  irregular,  especially  under 
atropine;  the  iris  is  streaked  with  lymph,  dull,  swollen,  and  discolored.  On 
very  careful  inspection  a  faint  pink  zone  of  congestion  may  be  seen  in  the 
sclerotic,  though  this  is  often  wanting. 

The  prognosis  is  generally  good;  even  when  the  pupil  has  been  occluded, 
vigorous  treatment  will  cause  absorption  of  the  plastic  exudate. 

The  treatment  consists  in  the  administration  of  mercury;  it  is  often  useful 
to  give  it  in  combination  with  tonics.  When  the  disease  occurs  during  intra- 
uterine life,  the  infiltration  is  liable  to  extend  to  the  lens,  rendering  it  opaque; 
the  same  result  often  follows  when  the  disease  develops  after  birth  and  is 
not  recognized.  In  this  form  of  lens  opacity  the  operation  for  cataract  promises 
little  good. 

Optic  neuritis,  retinitis,  and  choroiditis  are  occasionally  observed  in  the  course 
of  hereditary  syphilis. 

Hereditary  Syphilis  Affecting  the  Ear 

Extension  of  inflammation  from  the  throat  and  blocking  of  the  Eustachian 
tube  may  cause  chronic  middle-ear  disease,  with  consequent  deafness. 

The  characteristic  syphilitic  otitis  media  is  that  which  develops  painlessly, 
usually  within  a  few  weeks  or  a  few  months  of  birth,  and  gives  rise  to  no 
symptoms  except  a  purulent  discharge,  thus  differing  markedly  from  the  ordinary 
suppurative  otitis  media,  which  is  not  uncommon  in  infancy  and  childhood. 
This  syphilitic  otitis  yields  promptly  and  completely  to  specific  treatment. 
If  neglected  it  becomes  chronic,  producing  irremediable  changes,  which  result 
in  partial  deafness,  suppuration  of  the  mastoid  cells,  and  bone-involvement. 

Deafness  is  characterized  by  Hutchinson  as  one  of  the  cardinal  symptoms 
of  hereditary  syphilis.  It  is  due  to  labyrinthine  changes,  usually  affecting 
both  ears.  These  changes  in  the  case  of  an  infant  are  unaccompanied  by 
subjective  symptoms,  but  result  in  deaf-mutism. 

When  the  labyrinth  is  attacked  later,  at  about  the  time  of  puberty,  for 
instance,  there  may  be  as  a  premonitory  sign  painless  tinnitus.  Deafness 
develops  rapidly,  is  complete,  and  is  apparently  causeless.  Treatment  is 
often  unavailing. 

Hereditary  Syphilis  Affecting  the  Teeth 

The  first  teeth  exhibit  malformations  and  imperfections  which  are  by  no 
means  characteristic  of  syphilis,  but  which  may  be  referred  to  any  inflamma- 
tion of  the  gums  sufficiently  severe  to  interfere  with  the  nutrition  of  the  tooth- 
sacs.    Thus,  the  teeth  are  often  deficient  in  enamel,  or  this  coating  is  unevenly 


836  GEXITO-URINARY  SURGERY 

distributed,  or  is  opaque  and  chalky,  or  the  dentine  is  soft  and  friable,  or  the 
teeth  are  incongruous  in  size  individually  and  relatively,  and  decay  readily. 

The  permanent  teeth  may  exhibit  the  same  perversions  of  growth  and 
nutrition  as  a  result  of  stomatitis,  whether  this  inflammation  be  produced  by 
mercury,  by  gastro-intestinal  derangements,  or  by  local  irritation.  jMercurial 
teeth,  for  example,  are  irregularly  outlined,  horizontally  seamed,  honey-combed, 
scraggy,  malformed,  of  an  unhealthy,  dirty  yellow  color,  separated  too  widely, 
and  deficient  in  enamel. 

Fournier  has  written  as  follows  concerning  the  influence  of  hereditary  s>'philis 
on  the  dental  organs:  The  transmitted  taint  shows  itself  on  the  dental  system 
in  two  series  of  manifestations,  of  very  unequal  diagnostic  value:  first,  by 
retardation  of  evolution;  second,  by  arrest  of  growth  and  modifications  of 
structure. 

Retardation  of  Evolution. — This  generally  applies  to  the  entire  first 
denture.  In  some  cases  it  is  limited  to  one  group  of  teeth — the  incisors,  for 
example.  A  similar  retardation  sometimes  is  noted  in  the  eruption  of  the  per- 
manent teeth.  This  is  but  a  localized  expression  of  the  general  lack  of  develop- 
ment characteristic  of  hereditary  syphilis. 

AiiREST  OF  Growth  and  ^Modifications  of  Structure. — Perversions  of 
growth  may  be  classified  under  dental  erosions,  microdontism,  dental  am.orphism, 
and  vulnerability.  Some  rarer  peculiarities,  such  as  irregularity  of  alignment  and 
anomalies  of  reciprocal  arrangement,  are  not  included  under  any  of  the  above 
headings. 

The  term  syphilitic  tooth  impHes  a  congenital  dental  malformation,  a 
deficiency  of  development  stamped  by  syphilis  on  the  tooth  yet  unformed  during 
the  period  of  its  intrafoUicular  evolution.  The  first  dentition  is  not  so  often 
influenced  as  the  second.  The  dental  malformations  are  commonly  multiple 
and  symmetrical — that  is,  several  teeth  are  affected,  and  usually  corresponding 
teeth  show  similar  lesions. 

Dental  Erosion. — This  malformation  may  implicate  any  portion  of  the 
surface  or  borders  of  the  tooth.  Its  common  manifestation  on  the  front  of 
the  tooth  is  a  cupping,  comparable  to  the  slight  depression  which  would  be  left 
by  the  point  or  the  head  of  a  pin  in  soft  wax.  These  cuppings  show  a  dark 
tint,  grayish,  brownish,  or  almost  black,  and  in  the  deeper  depressions  enamel 
is  entirely  wanting.  Erosions  in  this  form  are  most  common  on  the  incisors, 
and  notably  on  the  superior  centrals,  and  are  often  arranged  in  one  or  more 
horizontal  rows. 

The  furrowed  erosion  is  the  commonest  form,  and  appears  as  a  transverse 
groove,  which  may  make  the  entire  circuit  of  the  tooth,  or  may  be  broken. 
The  groove  may  be  so  shallow  as  to  form  a  scarcely  perceptible  streak,  or  it 
may  be  deep,  as  though  filed,  producing  an  unsightly  deformity,  since  it  soon 
acquires  a  dark  tint.  These  furrows  are  always  horizontal  and  usually  single. 
Sometimes  two  or  three  are  noticed  on  the  same  tooth,  occupying  the  portion 
of  the  crowTi  nearest  the  free  edge.  In  such  teeth  the  free  extremity  is  gen- 
erally worn  thin,  partly  or  ^otally  deprived  of  enamel,  rough,  uneven,  irregular. 
browTiish,  and  rapidly  wears  away.  These  grooved  erosions  are  most  frequent 
on  the  incisors. 


HEREDITARY  SYPHILIS  837 

Surface  erosion  is  rare.  It  represents  simply  an  exaggerated  form  of  the 
grooved  erosion,  covering  a  large  surface  of  the  crown  and  presenting  a  wide, 
unequal,  and  rough  zone  filled  with  alternate  points  and  sinuosities  and  of  a 
dirty  yellow  or  blackish  color. 

The  malformations  affecting  the  cutting  or  grinding  surfaces  of  the  teeth 
present  themselves  under  different  forms,  according  to  the  class  of  teeth  they 
affect. 

The  first  moiar  is  the  only  one  among  the  grinders  upon  which  the  influence 
of  hereditary  syphilis  shows  itself.  The  body  of  the  tooth  for  two-thirds  or 
three-fourths  of  its  height  is  normal;  its  upper  surface  is  atrophied,  suggesting 
a  stump  of  dentine  emerging  from  a  normal  crown.  The  masticating  surface  is 
rough  and  of  a  dirty-yellow  or  brown  tint,  and  wears  away,  producing  a  fiat 
surface  with  a  yellowish  centre  and  a  peripheral  border  of  white  enamel.  This 
short,  flat  tooth  has  a  diagnostic  significance  of  high  value. 

Upon  the  cuspids  erosion  of  the  free  edge  may  appear  as  a  simple  notch, 
similar  to  a  cut  made  in  a  piece  of  wood  by  two  convergent  strokes  of  a 
knife,  or  as  a  true  atrophy,  producing  the  appearance  of  a  slender  conical 
stump  grafted  in  a  cylinder. 

Erosions  of  the  cutting  edge  of  the  incisors  are  more  numerous.  There 
may  be  an  angular  notch,  serration,  atrophic  thinning,  with  antero-posterior 
flattening,  or  general  atrophy,  the  tooth  presenting  a  normal  base,  from  which 
emerges  a  small,  rough,  dirty-gray  stump  with  an  uneven  surface. 

Finally,  there  is  the  crescent-shaped  erosion  characterized  by  a  semilunar 
notch,  constituting  the  Hutchinson  tooth.  The  important  peculiarity  of  this 
last  erosion  is  the  semicircular  cut  in  the  free  edge  of  the  tooth.  The  superior 
central  incisors  are  the  teeth  which  exhibit  this  characteristic  crescentic  notch. 
It  is  impossible  to  mistake  it  or  seriously  to  consider  it  in  connection  with  any 
other  affection  of  the  dental  organs.  The  crescentic  notch  is  the  essential  char- 
acteristic of  the  Hutchinson  tooth,  but  is  not  the  exclusive  one.  The  notch 
is  nearly  always  bevelled  at  the  expense  of  the  anterior  edge  of  the  tooth;  in 
other  words,  the  anterior  border  of  the  crescentic  arch  is  cut  obliquely  from 
above  downward  and  from  before  backward.  The  typical  Hutchinson's  tooth 
is  also  marked  by  its  rounded  angles,  the  lateral  and  inferior  borders  merging 
by  a  curved  line;  it  is  much  reduced  in  length;  sometimes  it  is  narrowed. 
Finally,  the  upper  central  incisors  having  the  Hutchinson  notch  often  deviate 
from  normality  in  direction,  and  their  axes  in  place  of  being  parallel  are 
obliquely  convergent. 

A  perfect  type  of  this  tooth  is  best  observed  in  youth.  It  does  not  protrude 
from  the  gum  with  a  clearly  cut  notch,  appearing  first  with  this  notch  either 
partially  or  completely  filled  by  small  or  apparently  atrophied  vegetations  of 
the  dental  tissue.  Deprived  of  enamel,  these  vegetations  are  rapidly  destroyed, 
leaving  in  their  place  the  smooth  crescentic  notch,  the  depth  of  which  pro- 
gressively diminishes  with  use.  At  twenty-five  years  the  vault  becomes  nearly 
flat,  but  even  then  there  remains  the  bevel  of  its  anterior  edge.  Later  with 
the  wearing  of  the  tooth  the  bevel  disappears,  so  that  beyond  the  age  of  thirty 
years  Hutchinson's  teeth  are  not  to  be  found.  This  dental  malformation  com- 
monly affects  the  two  teeth  symmetrically,  often  exclusively.     Sometimes  it 


838  GENITO-URINARY  SURGERY 

is  observed  in  the  upper  lateral  incisors,  the  inferior  incisors,  or  even  the  cuspids. 
Hutchinson  teeth  are  very  rarely  seen. 

In  the  second  dentition  dental  erosions  are  met  with  in  the  following  order 
of  frequency:  first,  on  the  first  molars,  particularly  those  of  the  lower  jaw; 
second,  on  the  incisors;  third,  on  the  cuspids.  The  bicuspids  and  second  and 
third  molars  are  almost  invariably  exempt  from  these  erosions. 

Erosions  are  usually  multiple  and  nearly  always  symmetrical.  Those  of 
corresponding  teeth  maintain  the  same  level  on  the  crown. 

Atrophy  of  the  dental  cusp,  notably  that  affecting  the  first  molar,  and 
constituting  the  short,  fiat  tooth,  has  a  more  precise  meaning,  because  this  is 
a  favorite  form  of  the  malformation  when  caused  by  syphilis. 

The  best  form — one  which  can  be  given  as  suggestive  evidence  of  syphilitic 
heredity — is  the  semilunar  notch  of  the  free  border  of  the  central  superior 
incisors. 

Microdontism,  implying  an  unusual  smallness  of  the  teeth,  most  frequently 
affects  the  superior  and  inferior  lateral  incisors. 

Amorphism,  or  departure  from  normal  shape,  is  almost  as  frequent  as 
erosion.  The  teeth  may  present  simply  deviation  of  normal  type,  or  they  may 
be  grossly  malformed. 

Erosion,  microdontism,  and  amorphism  may  be  associated.  The  tooth 
affected  by  syphilis  is  always  vulnerable.  Caries  develops  at  an  early  age. 
The  first  molars  being  the  teeth  most  exposed  to  these  degenerations  are  often 
destroyed  in  youth.  Irregularities  of  implantation  are  frequent,  the  teeth 
being  often  separated  from  one  another  by  large  empty  spaces. 

When  the  two  upper  central  incisors  are  stunted,  abnormally  narrow  at  the 
cutting  edge,  crescentically  rounded  with  the  convexity  upward,  and  the  surface 
inclined  upward  and  forward  instead  of  backward,  as  in  normal  teeth,  widely 
separated,  but  converging  at  their  lower  edges,  they  are  indications  of  hereditary 
syphilis.  Other  lesions  of  the  enamel  or  dental  substance,  possibly  with  the 
exception  of  the  incomplete  development  of  the  first  molar  described  by  Four- 
nier,  although  frequently  caused  by  hereditary  syphilis,  may  be  due  to  other 
dyscrasiae,  and  in  themselves  are  not  characteristic. 

Hereditary  Syphilis  Affecting  the  Bones  and  Joints 

The  bones  are  more  frequently  involved  in  hereditary  syphilis  than  in  the 
acquired  disease.  They  are  usually  attacked  between  the  fifth  and  the  nine- 
teenth years  of  age  (Fournier),  by  preference  the  bones  of  the  cranium  and 
nose  and  the  long  bones,  particularly  the  tibia. 

As  in  acquired  syphilis,  the  essential  lesions  are  those  of  periostitis,  ostitis, 
osteomyelitis,  and  gummatous  infiltration.  They  are  usually  formative  rather 
than  destructive  in  type. 

Osteochondritis  occurring  at  the  diaphyso-epiphyseal  junction  of  the  long 
bones  is  pathognomonic  of  syphilis.  It  is  characterized  by  a  marked  widening 
of  the  cartilaginous  plate  between  the  epiphysis  and  the  diaphysis,  by  irregular 
growth  of  the  bone  layer  just  beneath  the  cartilaginous  plate,  and  by  softening 
at  this  point   of  juncture,   allowing  epiphyseal    separation.     Microscopically 


HEREDITARY  SYPHILIS  839 

there  is  found  a  proliferation  of  cartilage  cells  and  an  arrest  in  the  transforma- 
tion of  these  cells  to  bone. 

The  symptoms  of  this  form  of  osteochondritis  are  as  follows: 

The  bones  most  frequently  attacked  are  the  humerus,  radius,  ulna,  tibia, 
and  femur,  but  the  ribs,  sternum,  and  bones  of  the  metatarsus  and  metacarpus 
are  also  often  invol't^ed. 

There  is  a  swelling  at  the  diaphyso-epiphyseal  junction  of  the  bone  or  bones 
involved,  appearing  in  the  form  of  a  smooth  ring  or  collar,  which  more  or  less 
completely  surrounds  the  bone.  In  the  course  of  some  weeks,  as  the  swelling 
becomes  more  pronounced,  there  may  be  a  moderate  amount  of  synovitis  present, 
particularly  when  the  disease  is  placed  about  the  knee  or  the  elbow-joint.  At 
this  stage — i.e.,  that  of  overgrowth  and  infiltration — the  lesion  is  readily  influ- 
enced by  specific  treatment  and  well-regulated  pressure. 

If  liquefaction  of  the  infiltrate  takes  place  there  is  complete  separation  of 
the  epiphyses  and  diaphyses,  shown  by  preternatural  mobility  and  syphilitic 
pseudo-paralysis,  the  affected  limbs  losing  all  power.  The  lesions  of  osteo- 
chondritis are  usually  multiple. 

The  bones  of  the  skull,  particularly  the  parietal,  frontal,  and  occipital,  are 
affected  by  formative  lesions. 

Lack  of  symmetry  is  especially  frequent  and  characteristic.  Fournier  has 
described  a  number  of  types:  thus,  there  are  the  broad,  high,  bulging  forehead; 
the  bossed  forehead,  the  projections  on  either  side  corresponding  to  the  frontal 
eminences,  with  an  apparent  depression  in  the  middle;  and  the  keeled  or 
chicken-breasted  forehead,  with  a  median  projection.  The  asymmetry  in  these 
cases  is  due  to  formative  osteoperiostitis  of  the  frontal  bones.  When  the 
parietal  bones  are  affected  there  results  the  natiform  skull,  presenting  appar- 
ent broadening  of  the  cranium,  with  a  central  depression,  suggesting  the  shape 
of  the  nates.  When  the  nodes  or  exostoses  are  found  in  the  regions  of  the 
frontal  and  parietal  eminences  they  are  often  called  "  Parrot's  nodes." 

The  degenerative  lesions  of  the  skull  are  characterized  by  swelling,  softening, 
breaking  down,  and  extensive  ulceration  and  destruction  of  bone-tissue.  After 
the  first  few* years  of  Hfe  the  cranium  is  rarely  affected;  the  bones  of  the  nose, 
however,  are  not  spared. 

When  the  bones  of  the  nose  and  face  are  involved  it  is  usually  from  an 
extension  of  disease,  which  primarily  attacks  overlying  soft  parts. 

With  regard  to  the  long  bones,  the  tibia  is  the  telltale  above  all  others. 
Swellings  and  nodes  are  the  rule,  deforming  the  diaphysis,  either  flattening  out 
the  crest  or  by  bony  deposits  curving  it.  This  sabre-shaped  tibia  is  an  impor- 
tant evidence  of  hereditary  syphilis.  The  chicken-breasted  thorax  is  also  fre- 
quently observed. 

Exceptionally  syphilis  manifests  itself  in  the  form  of  a  rarefying  ostitis, 
predisposing  to  fracture. 

Diagnosis. — The  bone-lesions  of  hereditary  exostoses  can  be  recognized 
by  the  fact  that  they  are  stationary,  appear  later  than  those  of  syphilis  and  are 
of  larger  size,  are  accompanied  by  no  S3TDhilitic  history  or  symptoms,  and 
resist  specific  treatment.  Sj^hilitic  osteochondritis,  followed  by  separation  of 
the  epiphyses  and  complicated  by  suppuration  and  sinuses,  may  be  mistaken 


840  GENITO-URINARY  SURGERY 

for  a  similar  condition  due  to  non-specific  inflammations;  the  latter,  however, 
occur  much  later  in  life,  are  attended  with  more  acute  inflammatory  symptoms,, 
and  are  not  accompanied  by  other  symptoms  or  traces  of  syphilis. 

The  characteristics  of  the  specific  and  of  the  non-specific  osteoperiostitis, 
may  be  thus  contrasted: 

Syphilitic  Osteoperiostitis.  Non-SpeciHc  Osteoperiostitis 

Occurs    in    infants    under    three    months  Seldom,     if     ever,     occurs     in     children 

of   age.  under  one  year  of  age. 

History     of  syphilis     in     child     and     its  No     history     of     syphilis;     sometimes     a 

parents.  history  of  traumatism. 

Implication  of  other  bones.  Usually  confined  to  one  bone. 

Coincident   with   the   development   of   the  Coexists     with     the     ossification     of     the 

shaft    of    the    bone.  epiphyses. 

Other    lesions    of    syphilis — nodes,    skin-  No  such  symptoms. 

eruptions,  etc. 

All    the    local    symptoms    comparatively  Pain,  redness,  and  swelling  very  marked. 

mild. 

Disease  sharply  localized.  Involves   neighboring  parts. 

Lymphatics   of  limb  unaffected.  Lymphangitis  sometimes  present. 

Beneficial   effect   of   specific  treatment   if  No  such  effect. 

employed  early. 

Wassermann  positive.  Wassermann  negative. 

Rickets  frequently  complicates  syphilis.  As  in  the  case  with  tuberculosis^ 
which  often  runs  its  course  in  conjunction  with  hereditary  syphilis,  rickets  is  a 
distinct  disease.  It  rarely  begins  in  the  first  nine  months,  exhibits  the  pro- 
dromata  of  gastro-intestinal  disturbances,  sweating  and  hyperaesthesia,  and  in 
its  progress  epiphyseal  enlargements,  particularly  of  the  ribs,  bone  deformity, 
delayed  closure  of  the  fontanelles,  delayed  dentition,  and  usually  a  failure  to 
stand  and  walk  at  the  normal  period.     The  two  conditions  may  be  combined. 

Syphilitic  dactylitis  commonly  develops  in  infants.  The  infiltration  may 
affect  the  subcutaneous  and  periarticular  tissue,  or  the  disease  may  begin  in  the 
bone  or  periosteum  and  later  involve  the  fibrous  structures  about  the  joints. 

The  deep  form  is  a  specific  osteomyelitis,  and  often  destroys  the  bone  and 
the  articulation.    The  articular  ends  of  the  first  phalanges  are  usually  affected. 

Symptoms. — Syphilitic  dactylitis  is  characterized  by  the  appearance  of 
an  ill-defined,  fusiform,  purplish  swelling,  which  softens,  breaks  down,  and 
discharges  (Fig.  420).  The  lesions  are  often  multiple,  painless,  affect  the  fingers 
rather  than  the  toes,  and  in  the  more  serious  forms  lead  to  destruction  of  tissue 
and  marked  interference  with  growth. 

Diagnosis. — Specific  dactylitis  is  not  easily  differentiated  from  tuberculous 
inflammation.  In  the  absence  of  bacteriological  or  serological  findings,  or  the 
corroboration  afforded  by  associated  symptoms,  the  distinction  should  be  made 
by  the  test  of  treatment.  This  is  supplemented  by  curetting  or  resection  when 
abscesses  have  formed  and  dead  bone  is  present. 

The  Joints. — Fournier  describes  a  form  of  joint-involvement  which  he 
terms  arthralgia,  characterized  simply  by  pain.  It  is  apparently  causeless,  is 
irregular  in  onset,  varies  in  degree,  and  has  a  tendency  to  become  more  severe 
at  night. 

The  lesions  of  the  joints  are  practically  the  same  as  those  of  acquired 
syphilis.     Fournier  describes  three  forms  of  arthrosis.     The  first  presents  the 


HEREDITARY  SYPHILIS  841 

appearance  of  simple  chronic  hydrarthrosis.  Close  examination  shows  that 
the  affection  of  the  joint  masks  a  bone-lesion,  perhaps  an  epiphysitis  or  a 
periostitis. 

The  second  form  presents  the  symptoms  of  syphilitic  white  swelling.  There 
is  a  somewhat  globular  tumefaction  of  bony  hardness  made  up  almost  entirely 
of  an  extensive  hyperostosis  of  the  epiphyses,  aided  by  moderate  synovial 
effusion.  It  is  not  sensitive  and  does  not  occasion  pain.  Function  is  not 
materially  interfered  with. 

The  third  form  presents  deforming  arthropathies  dependent  upon  epiphyseal 
malformation.  The  shape  of  the  swelling  is  irregular  and  at  times  extraordinary. 
Osteophytes  materially  interfere  with  function,  and  sometimes  occasion  complete 
ankylosis.  When  they  are  developed  at  an  early  age  they  are  accompanied 
by  muscular  atroDhv  and  arrested  development  of  the  affected  part. 

Hereditary  Syphilis  Affecting  the  Lymph-Nodes 

The  enlargement  of  the  lymph-nodes  is  painless,  slow,  moderate  in  degree, 
and  without  tendency  to  suppuration.  There  is  no  progressive  increment  in  size, 
nor  do  such  enlargements  present  any  diagnostic  features.  The  anterior  cervical 
group  is  most  commonly  affected. 

Hereditary  Syphilis  Affecting  the  Nervous  System 

The  Brain. — The  lesions  which  attack  the  nerve-centres  are,  as  in  other 
regions,  primarily  vascular;  macroscopically  they  may  appear  as  diffuse  infiltra- 
tions or  gummata.  They  are  usually  multiple  and  diffuse,  and  with  protean 
symptoms. 

Paralyses  are  common.  These  may  be  limited  or  general;  when  they  are 
repeated,  multiple,  or  recurrent,  and  particularly  when  they  involve  symmetrical 
portions  of  the  body,  they  suggest  syphilis. 

Infiltrations  and  gummata  of  the  brain  and  its  meninges  have  been  observed 
at  birth;  they  are  shown  later  in  case  of  survival  by  physical  inaptitude, 
retarded  development,  impaired  mentality,  psychoses,  headache,  convulsions, 
paralyses.  Pronounced  cases  are  rare,  because  lesions  sufficient  to  produce 
them  are  nearly  always  fatal  in  early  Hfe. 

Late  hereditary  cerebral  syphilis  may  cause  persistent  headache,  intellectual 
asthenia,  epileptiform  convulsions,  paresis,  or  paralysis.  Its  course  may  be 
rapid,  corresponding  to  the  symptomatology  of  acute  or  subacute  meningitis 
or  cerebral  tumors,  or  may  be  chronic,  lasting  for  several  years. 

Diagnosis. — It  is  apparent  that  cerebral  syphilis  has  no  individual  symp- 
toms of  its  own:  hence  the  diagnosis  will  in  the  main  be  founded  upon  a 
history  of  syphilitic  antecedents,  the  evidence  of  laboratory  tests,  and  the 
effect  of  specific  treatment. 

The  Spinal  Cord. — Gummatous  infiltration,  as  in  acquired  syphilis,  may 
involve  the  membranes  or  the  cord  itself.  The  first  symptom  is  usually  paralysis 
of  the  legs.  WTien  the  seat  of  involvement  is  high  up  the  palsy  may  involve  the 
arms  also.    Paraplegia,  tabes,  and  disseminated  sclerosis  have  been  reported. 


842  GENITO-URINARY  SURGERY 

Hereditary  Syphilis  Affecting  the  Viscera 

The  Lungs. — The  lungs  are  more  frequently  attacked  by  hereditary  than 
by  acquired  syphilis.  The  disease  may  appear  as  gummata  or  as  a  dittuse 
infiltration. 

Gummata  of  the  lungs,  the  common  form  of  involvement,  affect  chiefly  the 
middle  and  lower  posterior  portions,  appearing  as  miliary,  pea-sized,  sometimes 
cherry-sized,  nodules. 

Diffuse  infiltration,  the  so-called  white  pneumonia,  is  often  associated  with 
gummata.  It  may  involve  several  lobules  or  lobes.  The  portion  of  the  lung 
affected  is  dense  and  of  a  lighter  color  than  normal,  due  in  part  to  the  anaemia 
incident  to  perivascular  connective-tissue  growth  with  thickening  of  the  vessel- 
coats.  The  alveoli  are  filled  with  epithelial  cells  undergoing  fatty  degeneration. 
Diffuse  infiltration,  if  extensive,  is  necessarily  fatal  at  birth.  Children  suffering 
from  this  lesion,  even  though  it  be  limited,  live  but  a  few  days  or  weeks. 

Diagnosis. — The  diagnosis  of  specific  lung-involvement  in  syphilitic  infants 
cannot  be  made.  Many  such  infants  perish  of  broncho-pneumonia;  this,  how- 
ever, is  an  expression  of  vulnerability  rather  than  of  the  localization  of  a  specific 
lesion. 

The  Liver.— Examinations  of  children  still-born  because  of  hereditary 
syphilis  show  that  lesions  of  the  liver  are  most  constant.  The  liver  may  be 
the  only  viscus  involved.  The  usual  form  is  a  diffuse  interstitial  hepatitis, 
though  true  gummatous  hepatitis  may  be  observed  at  birth.  There  is  marked 
enlargement,  the  liver,  always  disproportionately  large  in  young  children,  being 
sometimes  three  or  four  times  its  normal  size. 

The  only  symptom  which  excites  attention  is  the  enlargement.  Excep- 
tionally, from  obliteration  of  the  bile-ducts,  jaundice  develops. 

The  Spleen. — The  spleen  is  enlarged  at  birth  or  shortly  after  in  about 
twenty  per  cent,  of  the  cases  of  hereditary  syphilis.  The  lesion  usually  appears 
in  the  form  of  diffuse  interstitial  splenitis,  and  may  form  a  tumor  three  times 
the  size  of  the  normal  organ.  The  increase  in  size  seems  to  be  mainly  due  to  a 
simple  hypersemia.  Enlargement  of  the  spleen  is  a  valuable  aid  to  diagnosis. 
Moreover,  the  amount  and  persistence  of  the  swelling  give  an  approximate 
indication  of  the  severity  of  the  case. 

The  importance  of  splenic  enlargement  is  greatest  when  noticed  early — 
the  first  three  months  after  birth — since  at  this  period  enlargement  of  the  spleen 
due  to  rachitis  can  hardly  come  into  question. 

The  Pancreas  .^Diffuse  interstitial  infiltration  of  the  pancreas  has  been 
found  in  a  certain  percentage  of  the  more  malignant  cases  of  hereditary  syphilis. 
There  are  probably  no  symptoms  which  will  assist  in  the  detection  of  this 
involvement  during  life,  and  it  is  always  associated  with  lesions  of  other  organs 
far  more  serious  and  demanding  more  immediate  attention. 

The  Intestines. — During  the  early  secondary  period  lesions  corresponding 
in  type  to  those  appearing  on  the  skin  may  attack  the  intestines.  The  passage 
of  blood  by  the  bowel  would  probably  be  the  only  sign  on  which  a  diagnosis 
could  be  formed.  Ulcerating:,  gummatous  infiltrations,  rare  in  any  event,  are 
more  common  in  congenital  than  in  acquired  syphilis,  though  it  must  be  remem- 


HEREDITARY  SYPHILIS  843 

bered  that  this  statement  is  founded  on  examinations  of  malignant  and  fatal 
cases  of  congenital  syphilis. 

The  Kidneys. — Cassell  reports  six  cases  of  albuminuria  in  thirty-one  infants 
with  inherited  syphilis.  Interstitial  and  peri-adventitial  proliferation  and  cystic 
degeneration  of  the  glomeruli  were  the  lesions  found. 

Hereditary  Syphilis  Affecting  the  Testicles 

This  rare  manifestation  of  hereditary  syphilis  usualh"  develops  in  the  first 
year  of  life.  The  testicle  slowly  and  painlessly  enlarges.  The  epididymis  may 
be  involved  in  the  swelling,  and  there  may  be  an  associated  h3-drocele.  Soften- 
ing and  ulceration  rarely  occur,  resolution  ultimately  taking  place,  often  followed 
by  pronounced  atrophy  of  the  gland. 

Diagnosis, — Xon-traumatic  enlargement  of  the  testicle  in  infancy  should 
always  suggest  syphilis  or  tuberculosis.  If  the  tumor  never  reaches  great  size, 
shows  no  tendency  to  ulcerate,  and  primarily  attacks  the  testis,  it  is  probably 
syphilitic. 

Prompt  treatment  will  prevent  atrophy. 

Diagnosis  of  Inherited  Syphilis 

In  reviewing  the  general  course  of  a  case  of  inherited  syphilis  it  becomes 
evident  that  the  differences  between  it  and  the  acquired  disease  are  seeming 
rather  than  real.  The  primary  stage  in  inherited  syphihs  is  of  course  wanting, 
and  the  tertiary  stage  is  apt  to  appear  unusually  early. 

Early  Hereditary  Syphilis.- — The  diagnosis  of  inherited  s^'philis  in  its 
early  stages,  at  birth  and  shortly  after,  will  be  founded  on — 

1.  A  history  of  parental  syphihs.  The  probability  of  the  transmission  of 
the  disease  is  increased  if  the  parental  syphilis  was  recent  at  the  time  of 
conception. 

2.  A  history  of  abortions  or  miscarriages  on  the  part  of  the  mother,  particu- 
larly if  such  accidents  have  been  frequent,  or  of  the  successive  births  of  several 
living  children  who  survived  but  a  short  time. 

3.  A  foetus  or  still-born  child  showing  (c)  osteochondritis,  readily  detected 
by  splitting  the  long  bones,  particularly  the  radius,  ulna,  humerus,  tibia,  and 
femur,  through  the  diaphyso-epiphyseal  juncture.  In  place  of  the  regular  nar- 
row line  marking  the  apposition  of  bone  to  cartilage,  there  is  a  broad,  irregular, 
yellow  line;  (b)  enlargement  of  the  liver  and  spleen;  (c)  the  lesions  of  inter- 
stitial pulmonitis;  true  gummata,  or  catarrhal  phenomena,  with  fatt}'  degenera- 
tion; {d)  papular,  pustular,  or  ulcerating  lesions,  or  bullae  which  exhibit  the 
characteristics  of  syphilitic  pemphigus.  jMaceration  of  the  epidermis  and  its 
elevation  into  bullae  are  scarcely  characteristic,  though  distinctly  suggestive, 
(e)  Arachnitis  with  hydrocephalus.  (/)  Arrested  development  and  evidence  of 
profound  malnutrition. 

4.  A  living  child  prematurely  born,  or  carried  to  full  term,  showing  the 
lesions  of  syphilis  at  birth  or  shortly  developing  them.  \Miether  the  syphihtic 
child  be  stunted,  emaciated,  wizened,  and  senile  at  birth,  or  be  well  nourished, 
cutaneous  or  mucous  membrane  eruptions  and  other  evidences  of  syphilis  are 


844  GEXITO-URIXARY  SURGERY 

often  absent.  In  a  few  weeks,  or  at  most  two  or  three  months,  highly  char- 
acteristic symptoms  develop.  The  more  prominent  of  these  are  snuffles,  hoarse- 
ness of  the  voice,  s\'philides  of  the  skin  and  mucous  membrane,  enlargement 
of  the  liver  and  spleen,  inflammation  of  the  iris,  profound  cachexia,  and  specific 
inflammation  at  the  junction  of  the  epiphyses  and  diaphyses  of  the  long  bones, 
sometimes  producing  a  condition  termed  S3^hilitic  pseudo-paralysis. 

Upon  the  presence  of  these  symptoms  the  diagnosis  of  hereditary  syphilis 
%^ill  be  founded  in  the  first  year  in  life. 

Prognosis. — The  prognosis  of  early  hereditary  symptoms  is  unfavorable 
if  cachexia  is  marked,  if  the  symptoms  show  themselves  early,  if  the  nasal  or 
laryngeal  affection  is  severe,  if  the  eruptions  are  markedly  bullar  or  pustulo- 
ulcerative,  if  the  enlargement  of  the  spleen  is  great,  if  the  osseous  lesions  are 
multiple  or  extensive,  and  especially  if  lesions  of  the  tertiary  type  develop  such  as 
gummata,  nodes,  etc.  ^Moreover,  the  syphilitic  infant  is  vulnerable  to  all  forms 
of  infection,  and  offers  a  feeble  resistance  against  them.  Hence,  though  living 
at  birth,  it  usually  survives  but  a  short  time. 

Late  Hereditary  Syphilis. — After  infancy  the  diagnosis  of  inherited 
syphilis  will  be  founded  on — 

1.  A  history  of  parental  or  infantile  syphilis,  or  both. 

2.  Imperfect  or  arrested  development.  This  is  manifested  by  many  symp- 
toms, none  of  which  are  individually  characteristic,  but  the  association  of  which 
is  pathognomonic.  The  common  expressions  of  this  developmental  retardation 
or  arrest  are — 

(c)  A  low  stature  and  puny  development.  The  figure  is  often  graceful 
and  symmetrical,  suggesting  infantilism  or  early  youth  long  after  these  periods 
have  passed,  or  the  appearance  may  be  that  of  premature  senility,  (b)  Pasty, 
leaden,  or  earthen  complexion,  (c)  Dryness  or  harshness  of  the  hair,  and 
brittleness  and  splitting  of  the  nails. 

3.  Active  manifestations  of  syphilis  or  traces  of  former  characteristic  lesions. 
(a)  The  forehead  bulging  in  the  middle  line,  or  bossed  in  the  region  of  the 
frontal  and  parietal  eminences,  (b)  A  flat,  sunken  bridge  of  the  nose,  due  to 
the  coryza  of  infancy  extending  to  the  periosteum  of  the  delicate  nasal  bones, 
interfering  with  their  nutrition  or  partially  destroying  them,  (c)  Dulness  of 
the  iris  (rare). 

4.  Ulceration  of  the  hard  palate  and  pharynx.  Thickening  or  enlargement 
of  the  long  bones  near  the  ends,  or  slight  angular  deformity,  the  result  of  the 
osteochondritis  of  infancy. 

5.  Hutchinson's  teeth. 

6.  Traces  of  interstitial  keratitis. 

7.  Cicatrices  about  the  lips  and  nares.  These  appear  in  the  form  of  narrow, 
radiating  scars,  extending  across  the  mucous  membrane  of  the  lips,  or  as  a  net- 
work of  linear  cicatrices  on  the  upper  lip  and  around  the  nostrils,  as  well  as  at 
the  corners  of  the  mouth  and  on  the  lower  lip  (Fig.  421). 

8.  Skin  cicatrices,  showing  rounded,  polycyclic,  or  serpiginous  outlines, 
especially  about  the  nose  and  the  gluteal  region. 

9.  Periosteal  nodes  on  one  or  many  of  the  long  bones,  or  irregularly  scattered 
over  the  skull. 


HEREDITARY  SYPHILIS  845 

10.  Sudden  and  complete  deafness  without  otorrhoea,  or  other  subjective 
symptoms,  or  a  history  of  sudden,  painless  otorrhoea  in  childhood. 

11.  In  addition  to  lesions  which  are  more  or  less  characteristic  of  syphilis 
and  are  generally  so  recognized,  retarded  development,  either  mental  or  physical, 
usually  both,  imperfect  coordination,  persistent  headache,  epileptiform  attacks, 
paralyses,  and  the  symptoms  of  paresis  and  ataxia  and  disseminated  sclerosis 
are  often  dependent  on  the  vascular  and  perivascular  infiltration  and  sclerosis 
of  syphilis. 

12.  A  positive  Wassermann  reaction. 

Prognosis. — The  prognosis  of  late  hereditary  s\^hilis  is  good  so  far  as  life 
is  concerned,  although  exceptionally  when  important  viscera,  such  as  the  lungs, 
the  brain,  the  liver,  or  the  kidneys,  are  attacked,  death  may  result  before  treat- 
ment can  accomplish  resolution  of  the  specific  infiltrate. 

The  treatment  of  hereditary  syphilis  is  given  in  Chapter  XLIV. 


CHAPTER  XLIII 
THE  LABORATORY  DIAGNOSIS  OF  SYPHILIS 

THEORY  AND  TECHNIQUE  OF  THE  WASSERMANN  REACTION 

The  serum  diagnosis  of  a  disease  depends  upon  detection  in  the  blood  of 
specific  antibodies  produced  by  the  reaction  of  the  body-cells  to  the  virus  of 
the  disease. 

If  a  foreign  substance  (antigen)  be  introduced  in  appropriate  quantities 
into  the  body  of  an  animal,  an  antibody  will  be  formed  in  the  blood-serum  of 
the  animal  to  overcome  the  action  of  the  substance  introduced,  and  the  animal 
is  said  to  be  immunized.  The  antibody  is  specific  only  for  the  particular  foreign 
material  in  question,  and  is  known  as  amboceptor.  This  process  of  immuniza- 
tion applies  to  various  substances;  for  example,  different  kinds  of  bacteria,  red 
blood-cells,  lipoids,  etc.  The  reaction  of  the  antigen  with  its  specific  amboceptor 
is  brought  about  only  in  the  presence  of  a  third  substance,  known  as  complement. 
Complement,  present  normally  in  all  blood-serum,  comes  into  play  in  the  reaction 
of  any  antigen  with  its  specific  amboceptor.  This  reaction  is  known  as  the 
complement-fixation  reaction.  Complement  normally  present  in  blood-serum 
is  thermolabile;  that  is,  it  is  destroyed  by  heating  the  serum  for  half  an  hour 
at  56°  C.  Amboceptor,  on  the  other  hand,  is  thermostabile,  and  is  not  de- 
stroyed by  moderate  heat.  The  reaction  of  bacterial  antigen  and  its  specific 
amboceptor  is  known  as  bacteriolysis,  that  of  red  blood-cells  and  hsemolytic 
amboceptor  as  haemolysis,  though  there  is  no  actual  solution  of  the  cells.  In 
haemolysis,  the  amboceptor  binds  itself  to  the  stroma  of  the  red  cell,  destroying 
the  osmotic  equilibrium  between  the  blood-corpuscle  and  the  surrounding  fluid 
and  causing  the  haemoglobin  to  be  set  free  and  to  enter  the  surrounding  fluid, 
giving  it  a  transparent  red  color,  easily  perceptible  to  the  naked  eye.  In  the 
case  of  bacteriolysis,  or  the  complement-fixation  reaction  of  syphilis,  it  is  diffi- 
cult or  impossible  to  see  that  the  reaction  has  taken  place.  Therefore,  a  haemo- 
lytic  system,  the  reaction  of  which  can  be  easily  seen,  is  introduced  as  an  indi- 
cator. This  application  of  the  principle  of  haemolysis  was  first  made  by  Bordet 
and  Gengou,  in  their  serological  experiments  with  cholera  spirilla. 

Nature  of  the  Antigenic  Substances, — Not  only  introduction  of  bacteria 
and  red  cells,  etc.,  themselves  can  produce  specific  amboceptors  in  the  blood- 
serum,  but  watery  and  alcoholic  extracts  of  the  bacteria,  red  cells,  etc.,  can 
be  employed  for  this  purpose,  and  can  be  used  as  antigen.  In  the  case  of 
bacterial  extracts  the  antigenic  properties  are  probably  contained  in  the  pro- 
tein material,  while  it  is  the  lipoid  substances  in  red  corpuscles  that  possess 
the  antigenic  power.  In  the  S3T3hilis  reaction,  also,  this  property  is  probably 
carried  by  the  lipoid  substances. 

In  the  preparation  of  a  haemolytic  system  for  diagnostic  purposes,  the  red 
blood-corpuscles  of  an  animal — in  the  present  case  a  sheep — are  injected  intra- 
peritoneally  or  intravenously  into  a  second  animal — a  rabbit — in  increasing 
846 


THE  LABORATORY  DIAGNOSIS  OF  SYPHILIS  847 

quantities  at  intervals  of  a  few  days.  By  this  means  the  blood-serum  of  the 
rabbit  acquires  a  very  high  haemolytic  power  for  the  red  cells  of  the  sheep, 
provided  that  a  suitable  amount  of  complement  be  present.  Thus  the  rabbit's 
serum  furnishes  the  amboceptor,  and  the  sheep's  red  corpuscles  the  antigen, 
of  the  haemolytic  system. 

The  principles  above  described  were  first  applied  to  the  diagnosis  of  syphilis 
by  Wassermann,  Neisser,  and  Bruck,  who,  in  the  absence  of  pure  cultures  of 
the  treponema  pallidum,  employed  as  antigen  watery  extracts  of  tissues  very 
rich  in  treponemata,  viz.,  the  liver  of  a  syphilitic  fcetus.  The  results  thus  ob- 
tained apparently  bore  out  the  theoretical  foundations  of  the  reaction,  though 
in  reality  the  explanation  of  the  reaction  in  syphilis  is  not  the  same  as  that 
in  bacterial  diseases  in  general,  since  alcoholic  extracts  of  normal  organs  (hu- 
man heart),  in  which  no  treponemata  are  present,  can  be  used  as  antigen 
with  as  reliable  results  as  extracts  of  syphilitic  tissues.  As  it  is  lipoid  sub- 
stances in  the  tissues  that  are  extracted  by  alcohol,  it  must  be  assumed  that 
the  antigenic  properties  are  contained  in  these  substances.  Further,  reliable 
results  have  been  obtained  by  the  use  of  articial  lipoid  as  antigen.  There 
is  thus  extracted  from  the  organs  an  entirely  non-specific  substance,  so  far 
as  treponemata  are  concerned,  which  combines  with  an  amboceptor  in  the 
syphilitic  patient's  serum.  Noguchi,  using  as  an  antigen  strains  of  the  trepo- 
nema pallidum  in  pure  culture,  has  demonstrated  a  positive  Wassermann  re- 
action in  all  the  known  syphilitic  sera  tested,  and  a  negative  reaction  in  non- 
syphilitic  cases,  thus  proving  that  there  is  a  specific  complement-fixation  reac- 
tion in  syphilis  as  in  the  case  of  other  bacterial  diseases. 

The  above-described  principles  are  applied  to  the  diagnosis  of  s>'philis  as 
follows: 

The  suspected  patient's  serum,  together  with  a  definite  amount  of  comple- 
ment (see  below)  and  extract  of  syphilitic  tissue  (antigen)  are  placed  in  a 
tube  and  incubated  at  37°  C.  for  one  hour,  or  immersed  in  a  water-bath  for 
one-half  hour  at  the  same  temperature.  At  the  end  of  that  time  no  visible 
change  has  occurred,  whether  complement  has  been  fixed  or  not.  To  deter- 
mine this  point,  sheep's  red  corpuscles  and  rabbit's  serum  possessing  a  high 
haemolytic  power  for  the  sheep's  corpuscles  are  added,  and  the  tube  incubated 
for  two  hours.  At  the  end  of  this  time,  if  no  haemolysis  has  occurred,  it  means 
that  the  complement  has  been  fixed  by  the  antigen  and  the  antibody  in  the 
patient's  serum,  leaying  no  complement  for  the  haemolytic  system,  and  the 
test  is  positive.  If  haemolysis  is  complete,  it  means  that  there  is  no  antibody 
in  the  patient's  serum  to  combine  complement  with  antigen ;  complement  is 
therefore  left  free  to  bring  about  haemolysis,  and  the  test  is  negative. 

Technique   of  Wassermann   Reaction 

Apparatus,  animals,  etc.,  required : 

Electric  centrifuge. 

4  graduated  centrifuge  tubes,   15   c.c.    (sterile). 

4  plain  centrifuge  tubes  (sterile). 

1  per  cent,  solution  of  sodium  citrate  in  normal  salt  solution  (sterile). 

Normal  salt  solution,  0.85  per  cent,   (sterile). 


348  GENITO-URINARY  SURGERY 

2  dozen  capillary  pipettes,  made  from  ^-inch  glass  tubing  (sterile). 
Rubber  nipples  for  capillary  pipettes. 

1  20-c.c.  all-glass  hypodermic  syringe   (sterile), 
100  glass  ampoules,  1  c.c.  (sterile). 

2  graduated  glass  cylinders,  100  c.c.  (sterile). 
2  flasks,  500  c.c.  (sterile). 

2  flasks,  100  c.c.  (sterile). 

1  centigrade  thermometer. 
Water-bath. 

Bunsen  burner. 

Wax  pencil  for  marking  glass. 

Triangular  file.  I 

Platinum  wire,  attached  to  glass  rod. 

Forceps,  scissors,  sterile  gauze. 

Ether. 

95  per  cent,  alcohol. 

100    test-tubes,  capacity  about  5  c.c.  (sterile) „ 

2  dozen  1-c.c.  graduated  pipettes  (sterile). 
2  graduated  pipettes,  10  c.c.  (sterile). 
Copper  boxes  for  holding  pipettes. 

2  wire  racks  for  holding  small  test-tubes. 

Racks  for  centrifuge  tubes. 

Incubator. 

Sterilizer. 

Ice-box. 

Sheep. 

Rabbits. 

Guinea-pigs. 

Preparation  of  Hasmclytic  System. — ^The  hgemolytic  system  employed 
consists  of  rabbit's  serum  immunized  against  sheep's  red  corpuscles.  The 
preparation  of  the  hgemolytic  system  should  be  undertaken  first,  as  it  some- 
times requires  four  or  five  weeks.  The  immunity  is  brought  about  by  in- 
jecting increasing  doses  of  sheep's  red  blood-corpuscles  into  the  peritoneal  cav- 
ity of  a  rabbit  at  intervals  of  four  or  five  days.  The  doses  found  to  be 
suitable  are  2,  3,  4,  5,  and  5  c.c,  approximately.  After  these  injections  a 
high  dilution  of  the  rabbit's  serum  will  produce  haemolysis  of  a  suspension 
of  sheep's  corpuscles  in  the  presence  of  complement.  The  standard  aimed  at 
is  haemolysis  of  1  c.c.  of  suspension  containing  approximately  1,000,000,000 
sheep's  corpuscles,  by  1  c.c.  of  a  1-2000  dilution  of  rabbit's  serum,  in  the 
presence  of  0.1  c.c.  of  complement.  Complement  exists  in  varying  quantities 
in  all  sera,  and  in  order  to  have  a  fixed  amount  in  the  test  the  natural  com- 
plement is  destroyed  by  heating  the  serum  over  a  water-bath  at  56°  C.  for 
three-quarters  of  an  hour.  This  process  is  known  as  inactivation  of  the  serum. 
The  complement  used  in  the  test  is  then  added  in  definite  quantity.  For  this 
purpose  normal  guinea-pig  serum  is  used,  as  it  has  been  found  to  be  fairly 
constant  in  regard  to  complement  content.  Addition  of  complement  to  any 
serum  previously  inactivated  is  known  as  activation. 


THE  LABORATORY  DIAGNOSIS  OF  SYPHILIS  849 

Collection  of  Blood  from  the  Sheep. — For  the  first  injection,  about  6  c.c. 
of  sodium  citrate  solution  is  placed  in  a  graduated  centrituge  tube,  and  brought 
up  to  10  c.c.  with  the  sheep's  blood  collected  by  puncturing  a  vein  of  the 
ear.  The  blood  and  the  sodium  citrate  are  weil  mixed  and  centrifuged. 
In  ten  minutes  the  red  corpuscles  should  have  collected  at  the  bottom  of  the 
centrifuge  tube,  amounting  in  bulk  to  about  2  c.c.  The  supernatant  clear 
fluid  is  drawn  off  with  a  capillary  pipette,  replaced  with  normal  salt  solution, 
and  the  whole  shaken  and  then  centrifuged  for  another  period  of  ten  minutes. 
This  washing  and  centrifuging  is  repeated  four  or  five  times  to  remove  all 
blood-serum,  as  injection  of  the  latter  might  cause  death  of  the  rabbit  from 
anaphylaxis.  The  corpuscles  are  then  drawn  up  into  an  all-glass  syringe  and 
injected  into  the  peritoneal  cavity  of  a  rabbit.  At  the  end  of  four  or  five 
days  a  second  injection,  consisting  of  3  c.c.  of  similarly  prepared  sheep's 
corpuscles,  is  made,  and  succeeding  doses  of  4,  5,  and  5  c.c.  are  given  at 
the  same  intervals. 

A  more  rapid  method  of  immunization  is  by  three  or  four  injections  of  y^ 
c.c.  of  10  per  cent,  emulsion  of  sheep's  corpuscles  into  the  ear  vein  of  the 
rabbit  at  the  same  intervals.  By  this  method,  also,  a  smaller  quantity  of 
corpuscles  is  required. 

Titration  of  Hccmolytic  Amboceptor. — Ten  days  after  the  last  intraperi- 
toneal, or  five  days  after  the  last  intravenous,  injection  the  hsemolytic  power 
of  the  rabbit's  serum  is  tested.  A  vein  in  the  ear  of  the  rabbit  is  punctured, 
and  3  or  4  c.c.  of  the  blood  are  collected  in  a  centrifuge  tube.  This  is  al- 
lowed to  clot,  and  the  serum  separated  by  centrifuging.  The  clear  serum  is 
drawn  off  with  a  capillary  pipette  and  complement  destroyed  (inactivated) 
by  heating  over  a  water-bath  for  three-quarters  of  an  hour  at  56°  C.  Dilu- 
tions of  the  serum  vnth.  normal  salt  solution  are  now  made  in  proportions  of 
1-500,  1-1000,  1-1500,  1-2000.  1-3000,  1-4000,  and  1-5000.  One  cubic  centi- 
metre of  each  of  these  dilutions  is  placed  in  a  small,  sterile  test-tube  with  1 
c.c.  of  a  suspension  of  sheep's  corpuscles  in  normal  salt  solution  in  the  propor- 
tion of  1,000,000,000  to  the  cubic  centimetre,  and  0.1  c.c.  of  the  guinea-pig 
serum  for  complem.ent.  This  mixture  is  then  brought  up  to  about  4  c.c.  by  the 
addition  of  normal  salt  solution,  and  thoroughly  mixed  by  inverting  the  tube 
several  times.  The  suspension  of  sheep's  corpuscles  is  prepared  by  adding 
one  part  of  whole  sheep's  blood  to  nine  parts  of  sodium  citrate  solution,  centri- 
fuging, washing  four  times  with  normal  salt  solution,  and  bringing  the  total 
quantity  up  to  the  original  volume  (10  c.c).  In  this  way  10  c.c.  of  a  uni- 
form suspension  of  approximately  1,000,000,000  red  corpuscles  to  1  c.c.  is 
obtained,  as  may  be  determined  by  actual  count  with  the  haemocytometer.  This 
method  of  preparing  hsemolytic  antigen  is  superior  to  that  of  making  a  5  per 
cent,  suspension  of  centrifuged  corpuscles,  which  cannot  be  measured  accurately 
on  account  of  variations  in  the  densit}^  of  the  emulsion  of  centrifuged  cor- 
puscles. 

The  mixtures  of  hsemolytic  amboceptor  (rabbit's  serum),  haemolytic  antigen 
(sheep's  corpuscles),  and  complement  (guinea-pig's  serum)  having  been  pre- 
pared, the  tubes  containing  them,  after  being  marked  with  the  dilution  of 
rabbit's  serum  in  each,  are  placed  in  the  incubator  for  one  hour  at  37°  C, 
54 


850  GENITO-URINARY  SURGERY 

or  immersed  in  a  water-bath  for  a  half  hour  at  the  same  temperature.  At 
the  end  of  this  time  the  tubes  are  removed  from  tne  incubator,  and  the  one 
containing  the  highest  dilution  that  shows  haemolysis  is  noted.  If  it  be  that 
marked  1-2000,  the  amboceptor  is  sufficiently  powerful.  If  haemolysis  occurs 
only  in  tubes  containing  lower  dilutions  (1-1000  or  1-SOO),  the  rabbit  re- 
quires further  immunization  with  sheep's  corpuscles,  and  one  or  two  more 
injections  of  5  c.c.  are  given,  after  which  the  titration  is  repeated.  More  than 
ten  days  should  not  elapse  before  repeating  an  injection.  Haemolysis  is  indi- 
cated by  complete  disappearance  of  the  corpuscles,  the  fluid  assuming  a  trans- 
parent red  color.  Absence  of  haemolysis  is  shown  by  the  corpuscles  falling  to 
the  bottom  of  the  tube,  the  overlying  fluid  being  transparent  and  colorless. 
Various  grades  of  haemolysis  are  seen  between  these  two  extremes.  When  the 
rabbit's  serum  shows  the  required  titre  of  1-2000,  the  animal  should  be  ether- 
ized and  bled  to  death  from  the  carotid  artery,  and  the  blood  collected  in  a 
sterile  fiask.  When  the  clot  separates,  the  clear  serum  is  drawn  off,  inacti- 
vated, and  sealed  in  1-c.c.  sterile  ampoules.  If  desired,  the  serum,  before 
placing  in  ampoules,  may  be  mixed  with  an  equal  quantity  of  glycerin,  which 
is  said  to  preserve  it  for  a  greater  length  of  time.  To  avoid  waste,  an  ampoule 
of  the  concentrated  serum  may  be  diluted  with  normal  salt  solution  to  a 
strength  of  1-100  and  kept  in  a  flask  on  ice  for  immediate  use,  the  further 
dilution  necessary  being  made  each  time  the  test  is  performed.  The  power 
of  the  amboceptor  can  be  maintained  in  this  way  for  two  or  three  weeks 
without  deterioration,  while  that  in  the  ampoules  will  keep  for  at  least  nine 
months. 

A  suspension  of  corpuscles  should  not  be  kept  longer  than  three  or  four 
days. 

Preparation  of  Complement. — In  contrast  to  amboceptor,  complement  loses 
its  power  quickly  and  cannot  be  preserved.  A  fresh  guinea-pig  should  be  killed 
every  time  the  test  is  made,  and  the  serum  used  as  soon  as  possible.  It  is 
only  by  using  fresh  complement  that  accuracy  in  the  test  is  attained.  The 
guinea-pig  is  etherized;  before  death  occurs  an  incision  is  made  in  the  neck, 
and  the  blood  from  the  carotid  artery  allowed  to  flow  into  a  sterile  centrifuge 
tube.  From  10  to  IS  c.c.  of  blood  should  be  obtained  from  one  animal.  After 
the  blood  clots  it  may  be  stirred  with  a  sterile  platinum  needle,  centrifuged, 
and  the  supernatant  clear  serum  drawn  off  with  a  capillary  pipette.  The  serum 
can  then  be  diluted  to  form  a  solution  of  1  in  10  with  normal  salt  solution, 
so  that  small  quantities  of  it  may  be  handled  accurately  with  a  graduated 
1-c.c.  pipette. 

Preparation  of  Syphilitic  Antigen, — This  is  prepared  by  making 
either  a  watery  or  an  alcoholic  extract  from  the  liver  of  a  syphilitic  foetus. 
Non-syphilitic  antigens,  such  as  those  prepared  from  normal  liver,  heart,  etc., 
are  used  satisfactorily  by  some  workers.  The  alcoholic  extract  of  syphilitic 
liver  prepared  after  the  directions  of  Lesser  is  to  be  preferred.  The  amount  to 
be  used  is  determined  by  titration  with  a  series  of  known  positive  and  known 
negative  sera.  One-third  of  the  amount  that  will  fix  complement  by  itself 
{i.e.,  without  the  presence  of  antibody),  is  employed  in  the  test.  The  dose  is 
usuallv  0.2  c.c.  of  a  five-times-diluted  extract. 


THE  LABORATORY  DIAGNOSIS  OF  SYPHILIS  851 

Collection  of  Patient's  Serum. — The  blood  may  be  obtained  either  from  a 
puncture  wound  in  the  tip  of  the  linger,  or  from  a  vein  through  a  needle. 
About  3  c.c.  are  required.  When  this  has  been  obtained  the  tube  is  sealed 
with  sterile  cotton  or  a  cork  and  placed  on  ice  until  required.  Patient's  serum 
should  not  be  kept  longer  than  six  days  before  testing.  When  the  clot  separates 
the  clear  serum  may  be  drawn  off  with  a  sterile  capillary  pipette  and  trans- 
ferred to  another  tube.  Sometimes  the  blood  must  be  stirred  with  a  sterile 
platinum  needle  and  centrifuged  before  the  serum  can  be  removed.  In  remov- 
ing the  serum  care  must  be  taken  not  to  draw  any  of  the  clot  into  the  pipette, 
to  avoid  having  any  but  sheep's  red  corpuscles  present  during  the  test,  as  the 
human  clot  would  remain  unchanged  in  the  tube  at  the  end  of  the  reaction 
and  possibly  give  rise  to  an  incorrect  reading. 

On  the  day  of  the  performance  of  the  test  the  following  procedures  are 
carried  out,  as  nearly  as  possible  in  the  order  here  given: 

1.  Preparation  of  the  suspension  of  sheep's  corpuscles. 

2.  Inactivation  of  the  patient's  serum. 

3.  Titration  of  complement. 

4.  Performance  of  the  test. 

1.  Preparation  of  Sheep's  Corpuscles. — Inasmuch  as  this  procedure  re- 
quires a  considerable  length  of  time,  it  is  started  first.  The  corpuscles  are 
collected  and  the  1,000,000,000  to  the  cubic  centimetre  suspension  prepared 
as  described.  Sufficient  blood  should  be  collected  to  make  3  c.c.  of  suspension 
for  each  case,  in  addition  to  4  c.c.  for  the  knowm  positive  and  negative  controls, 
and  4  c.c.  for  titration  of  complement. 

2.  Inactivation  of  the  Patient's  Serum. — Destruction  of  complement 
normally  present  is  brought  about  by  placing  the  tube  containing  the  serum 
in  a  water-bath  at  56-  C.  for  three-quarters  of  an  hour. 

3.  Titration  of  Complement. — This  is  perhaps  the  most  imiportant  part 
of  the  whole  test.  In  order  to  have  an  absolutely  accurate  reading,  we  must 
know  exactly  the  amount  of  complement  that  has  been  employed,  as  the  quan- 
titative estimation  of  antibody  in  the  patient's  serum  is  made  by  varying  the 
amount  of  complement.  In  the  original  standardization  of  the  haemolytic  ambo- 
ceptor 0.1  c.c.  of  guinea-pig's  serum  was  employed  as  complement.  In  the  test 
we  use  the  amboceptor  in  double  strength,  viz.,  1-1000,  and  must  ascertain 
the  amount  of  complement  necessarv^  for  this  dilution.  The  sera  of  different 
guinea-pigs  show  slight  variations  in  the  amount  of  complement  present.  Thus, 
while  0.05  c.c.  will  generally  be  required  for  haemolysis  when  using  a  1-1000 
dilution  of  amboceptor,  yet  at  times  a  smaller  or  a  greater  quantity,  such  as 
0.04  or  0.06  c.c,  is  the  correct  amount.  In  \dew  of  this  it  becomes  neces- 
sary to  ascertain  the  smallest  amount  of  complement  required  to  produce  hemol- 
ysis in  the  haemolytic  system  everv^  time  the  test  is  made.  An  excess  of 
this  w^ould  probably  give  a  negative  reading  in  a  positive  case.  Fresh  guinea- 
pig's  serum  is  obtained  and  a  1-10  dilution  made  by  adding  one  part  of 
the  serum  to  nine  parts  of  normal  salt  solution.  Into  four  tubes,  each  con- 
taining 1  c.c.  of  haemolytic  amboceptor  f  1-1000  dilution)  and  1  c.c.  of  sus- 
pension  of  sheep's  corpuscles    (1,000,000,000),    are  placed  0.03,   0.04.   0.05. 


852  GENITO-URINARY  SURGERY 

and  0.06  c.c.  of  the  diluted  complement;  0.2  c.c.  of  antigen  is  also  added  to 
each  tube  to  show  that  antigen  alone  will  not  interfere  with  haemolysis.  The 
tubes  are  now  incubated  at  37"  C.  for  half  an  hour.  The  smallest  amount 
of  complement  required  to  produce  complete  haemolysis  at  the  end  of  this 
time  is  employed  in  the  test,  and  constitutes  one  unit  of  complement.  This 
amount,  as  we  have  seen,  is  usually  0.05  c.c. 

4.  Performance  of  the  Test. — If  there  is  only  one  case,  six  tubes  are 
required,  one  containing  the  serum  to  be  tested,  and  the  remaining  five  being 
controls,  arranged  in  the  wire  rack  in  two  rows. 

Tube  1  in  the  front  row  contains  0.1  c.c.  of  inactivated  patient's  serum. 

Tube  2  in  the  front  row  contains  0.1  c.c.  of  inactivated  known  syphiHtic 
serum. 

Tube  3  in  the  front  row  contains  0.1  c.c.  of  inactivated  non-syphilitic 
serum. 

To  each  of  these  is  added  0.2  c.c.  of  syphilitic  antigen  and  1  unit  of  com- 
plement. 

In  the  back  row  are  three  control  tubes  for  Nos.  1,  2,  and  3  of  the  front 
row,  containing  the  three  sera  and  complement  in  the  same  amounts,  but 
no  antigen. 

The  total  contents  of  each  tube  are  now  brought  up  to  2  c.c.  by  adding 
normal  salt  solution,  mixed  by  inverting,  and  the  tubes  placed  in  the  incubator 
for  one  hour,  or  in  a  water-bath  for  a  half  hour,  at  37°  C,  to  permit  of  inter- 
action of  the  antigen  with  antibody  if  present  in  the  patient's  serum,  and 
consequent  fixation  of  complement.  The  tubes  are  then  removed  from  the 
incubator,  and  to  each  are  added  1  c.c.  of  haemolytic  amboceptor  (dilution  1- 
1000)  and  1  c.c.  of  suspension  of  sheep's  corpuscles  (1,000,000,000).  After 
mixing  the  contents  by  inversion,  the  tubes  are  again  placed  in  the  incubator 
at  37°  C.  for  two  hours.  At  the  end  of  this  time  a  preliminary  reading  may 
be  made,  and  the  tubes  are  set  in  the  refrigerator  over  night,  after  which  the 
final  result  is  read. 

Interpretation  of  Findings. — If  the  unknown  serum  is  strongly  positive, 
there  should  be  no  haemolysis  in  tube  No.  1  of  the  front  row,  because  all 
available  complement  was  fixed  by  the  interaction  of  antigen  and  antibody  in 
the  patient's  serum,  none  remaining  for  the  haemolytic  system.  For  the  same 
reason  there  should  be  no  haemolysis  in  tube  No.  2  of  the  front  row,  contain- 
ing the  known  syphilitic  serum.  In  the  remaining  four  tutes  there  should 
be  complete  haemolysis.  In  tube  No.  3  of  the  front  row,  containing  known 
negative  serum,  there  should  be  complete  haemolysis,  because  there  is  no  anti- 
body present  in  the  serum  to  combine  with  the  syphilitic  antigen  and  fix 
complement,  consequently  the  complement  is  left  free  to  act  with  the  haemolytic 
system  and  haemolysis  results.  This  same  reason  would  account  for  haemolysis 
in  tube  No.  1  of  the  front  row  if  the  patient's  serum  were  negative. 

In  the  back  row  all  tubes  should  show  complete  hjemolysis,  because  they 
contain  no  syphilitic  antigen  to  combine  with  antibody  if  present  in  the 
patient's  serum  and  fix  complement;  therefore,  complement  remains  free  to 
act  with  the  haemolytic  system.     Failure  of  complete  haemolysis  in  tube  No.  1 


RESULT 


Tube  1  Front 

Patient's  serum 

No 

Haemoly 

Partial 
sis     Haemolysis 

Partial           Complete 

Hfemolysis         Ha'emolysis 

rONA/ 

0.1  cc. 
Complement 

o 

p 

rt 

Amboceptor 
1  cc 

o 

F 
cr 

■ 

i      ' 

fi      B      n 

0.5  cc. 
Antigen      serum 

O 

3 

Corpuscles 
Ice 

o' 

3 

III 

If) 

(U 

0.2  CO. 

3- 

ZT 

u 

III 

+-» 

^ 

3tron^W+       Medium+       Weah:>+        Negati 

e 

1) 

°     Tube    1  BacK 

Patient's    serum 

Amboceptor 

complete  Haemolysis 

n 

lu                    row 

0.1  cc. 

n 

Ice. 

P 

1 

U 

Complement 

Corpuscles 

1 

0.5  c  c. 

Ice 

[f 

Tube  Z  Front 

Syphilitic     Serum 

5" 

5" 

No  Haemolysis 

row 

0.1  cc 

o 

c 

Amboceptor 

c 

Complement 
0.5  cc. 

g- 

(-1- 
o' 

3 

Ice 

Corpuscles 

0 
o' 

3 

H 

or 

'o 

i- 

Antigen 

Ice 

3- 

li 

§ 

0  2cc. 

3- 

n 

ri 

Strongly 

O 

OJ 

tt 

Complete  Haemolysis 

5    Tube  2  Back 

5\/phiiitic   Serum 

(.^ 

Amboceptor 

[1 

S                     ro^ 
£ 

0,1  cc 

Complement 

0.5  cc. 

p 

Ice 

Corpuscles 

tec. 

p 

1 

Tube   3  Front 

Non-Syphi/itic     Serum 

3 

5" 

Complete  Haemolysis 

r-1 

row 

0.1  cc. 

P 

Amboceptor 

1 

Complement 

CU 
ft 

Ice. 

H 

0.5  cc 

0 

3 

Corpuscles 

3 

H 

Antigen 

Ice 

_ 

■ 

0.2  cc 

3- 

Negatii/e 

U 

?; 

a 

Complete    Haemolysis 

5  Tube  3  BacK 

NIon-Syphilitic     Serum 

^-i 

Amboceptor 

W 

R 

"S                   row 

0.1  cc. 

o 

Ice 

o 

<D 

Complement 

Corpuscles 

H 

Z. 

0.5  cc. 

lee 

B 

THE  LABORATORY  DIAGNOSIS  OF  SYPHILIS  855 

of  the  back  row  shows  that  the  serum  in  it  contains  substances  capable  of 
fixing  complement  independently  of  antigen,  and  the  test  must  be  declared 
negative,  even  though  there  should  be  no  haemolysis  in  tube  No.  1  of  the 
front  row. 

Various  degrees  of  haemolysis  may  occur  in  tube  No.  1  of  the  front  row, 
ranging  from  complete  haemolysis,  indicating  a  negative  result,  to  absence  of 
haemolysis,  indicating  a  strongly  positive  result.  Thus  a  slight  degree  of 
haemolysis  is  read  as  a  medium  positive  reaction,  while  still  more  haemolysis 
is  called  weakly  positive. 

Quantitative  Estimation.- — Complete  absence  of  haemolysis  indicates  that 
the  quantity  of  antibody  present  is  capable  of  fixing  at  least  one  unit  of  com- 
plement. Stronger  reactions  than  this  can  be  measured  by  preparing  tubes 
containing  at  the  start  two  and  three  units  of  complement  as  well  as  one. 
Practically,  it  is  not  usual  to  carry  the  quantitative  estimation  beyond  two 
units.  For  this  purpose  we  place  two  tubes  of  patient's  serum  in  the  front 
row,  tube  (a)  containing  one  unit  of  complement  (O.OS  c.c.  guinea-pig's  serum), 
and  tube  {b)  containing  two  units  (0.1  c.c).  In  reading  the  end  result,  we 
may  find  no  haemolysis  in  tube  (a),  indicating  a  strongly  positive  result  of 
one  unit,  and  partial  or  complete  haemolysis  in  tube  (b),  showing  that  the 
antibody  in  the  patient's  serum  was  incapable  of  fixing  two  units  of  comple- 
ment.    Absence  of  haemolysis  in  tube  (b)  indicates  a  reaction  of  two  units. 

In  performing  the  test  on  more  than  one  case,  each  tube  containing  patient's 
serum  in  the  front  row  is  numbered,  and  we  must  have  a  control  behind  it  in 
the  second  row  containing  the  serum  but  no  syphilitic  antigen.  Of  course, 
one  positive  and  one  negative  control  will  answer  for  the  whole  series. 

As  a  means  of  measuring  the  amount  of  haemolysis  in  cases  showing  a  posi- 
tive reaction  of  less  than  one  unit,  the  Duboscq  colorimeter  has  been  found 
useful.  The  contents  of  the  control  tube  (back  row)  of  each  case  are  taken 
as  the  standard,  or  100  per  cent,  haemolysis.  This  is  placed  on  one  side  of 
the  instrument,  while  an  equal  amount  of  the  fluid  in  the  tube  to  be  tested 
is  drawn  off  from  the  undissolved  corpuscles  and  placed  in  the  other  side.  The 
screw  is  now  turned  until  the  two  fluids  have  the  same  color,  and  the  reading 
made.  It  is  essential  for  accurate  results  that  the  original  volume  of  fluid 
be  the  same  in  each  tube.  With  the  Duboscq  colorimeter  a  difference  in 
haemolysis  of  5  per  cent,  can  be  detected.  In  cases  submitted  for  diagnosis, 
over  90  per  cent,  of  haemolysis  should  be  regarded  as  negative;  between  90 
and  60  per  cent,  as  weakly  positive,  between  60  and  30  per  cent,  as  medium 
positive,  and  from  30  per  cent,  to  0  as  strongly  positive.  In  cases  previously 
distinctly  positive,  in  which  the  reaction  is  being  used  as  a  guide  to  treatment, 
from  90  to  95  per  cent,  of  haemolysis  should  still  be  regarded  as  positive. 
These  cases  should  not  be  called  negative  until  the  slightest  difference  in 
haemolysis  in  the  two  tubes  has  been  obliterated  by  treatment. 

The  accompanying  table  will  serve  to  illustrate  the  results  of  the  reactio"i 
(Plate  XIX) : 


g54  GENITO-URINARY  SURGERY 

Interpretation  of  the  Wassermann  Reaction 
Barring  the  existence  of  a  few  diseases,  noted  below,  the  presence  of  a 
positive  Wassermann  obtained  by  the  technique  given  is  indicative  of  syphilis; 
however,  in  the  absence  of  symptoms  suggestive  of  the  disease  the  diagnosis 
should  not  be  made  till  after  a  second  reaction  has  been  performed,  preferably 
by  a  different  laboratory,  A  doubtful  reaction  (partial  haemolysis)  may  not 
be  considered  diagnostic  under  such  circumstances.  The  diseases  other  than 
S3^hilis  in  which  a  positive  Wassermann  may  be  expected  are  yaws,  malaria 
(during  the  febrile  period),  leprosy,  relapsing  fever,  and  the  acidosis  of  diabetes. 
Pellagra  is  said  to  give  a  positive  reaction  when  cholesterin  is  used  as  antigen. 
The  reaction  commonly  becomes  positive  in  the  primary  stage  of  syphilis. 
Craig  ^  gives  the  incidence  in  the  several  weeks  of  the  chancre  as  follows: 
First  week,  36.3  per  cent.;  second  week,  59.3  per  cent.;  third  week,  68.9  per 
cent.;  fourth  week,  77.2  per  cent.;  fifth  week,  81.3  per  cent.  The  same  author 
thus  gives  the  incidence  of  positive  reactions  in  the  several  stages  of  the  dis- 
ease: Primary,  89.8  per  cent.;  secondary,  96.1  per  cent.;  tertiary,  87.4  per 
cent.;  latent,  68.1  per  cent.;  congenital,  95  per  cent.;  paresis,  98  per  cent.; 
tabes,  70  per  cent.;  cerebrospinal  syphilis,  50  per  cent.  The  percentage  of 
positive  reactions  in  the  cerebrospinal  fluid  in  these  last  diseases  varies  with 
the  amount  of  fluid  used;  using  1  c.c.  it  is  respectively  100  per  cent.,  95 
per  cent.,  and  100  per  cent.;  using  0.2  c.c,  75  per  cent.,  5  to  10  per  cent, 
and  10  per  cent. 

The  reaction  becomes  negative  through  the  influence  of  specific  treatment, 
of  alcohol,  and  in  some  cases  of  time.  Specific  treatment  acts  by  killing  and 
diminishing  the  activity  of  the  treponemata;  also  its  presence  in  the  system 
seems  to  have  an  effect  on  the  reaction,  so  that  it  is  inadvisable  to  take  blood 
for  a  test  within  a  month  or  six  weeks  of  the  administration  of  treatment. 
Craig  and  Nichols  have  shown  that  in  many  cases  alcohol  (240  c.c.  of  whiskey 
or  700  c.c.  of  beer,  sometimes  a  smaller  amount)  will  render  a  positive  serum 
negative.  The  effect  of  the  drug  lasts  about  three  days.  With  the  lapse  of 
time  untreated  cases  may  develop  a  negative  reaction;  also,  it  has  been  shown 
that  the  reaction  may  vary  in  intensity  or  quality  from  day  to  day — ^positive, 
doubtful,  negative,  etc.  It  is  therefore  quite  improper  to  base  a  diagnosis  on 
a  single  negative  reaction;  rather  the  reaction  should  be  performed  several 
times,  preferably  by  a  number  of  workers,  and  if  possible  before  and  after 
the  administration  of  a  "provocative"  dose  of  salvarsan  or  neosalvarsan  (0.2 
to  0.4  Gm.  of  salvarsan  or  its  equivalent),  the  blood  being  taken  thereafter 
daily  or  on  alternate  days  for  a  week,  as  the  effect  of  the  injection  varies  in 
different  individuals. 

Another  cause  of  accidental  negative  reactions  lies  in  infection  of  the  serum 
with  certain  strains  of  staphylococci  and  streptococci. 

The  Hecht-Weinberg-Gradwohl  Modification 

The  Hecht-Weinberg-Gradwohl  modification  utilizes  the  complement  and 
anti-sheep  haemolytic  substances  in  the  patient's  serum  by  not  inactivating  it. 
This  does  away  with  adding  guinea-pig  serum  and  an  anti-sheep  haemolytic 

'^American  Journal  of  Syphilis,   1917,   i,   192.    . 


THE  LABORATORY  DIAGNOSIS  OF  SYPHILIS  855 

amboceptor.  It  is  claimed  that  some  of  the  syphilitic  antibodies  are  thermola- 
bile  and  are  destroyed  by  the  process  of  inactivation.  It  is  claimed  also  that 
IS  per  cent,  more  positive  reactions  are  obtained  than  by  the  old  Wassermann 
reaction,  and  that  thus  negative  results  are  more  reliable  than  w^ith  the  original 
Wassermann  technique. 

Use   of   Different   Antigens 

A  large  number  of  serologists  employ  more  than  one  antigen  routinely. 
It  has  been  claimed  that  an  alcoholic  extract  of  human  heart  (normal)  re- 
inforced with  cholesterin  is  more  "sensitive"  than  the  alcoholic  extract  of  syph- 
ilitic liver,  and  will  result  in  a  greater  number  of  positive  reactions. 

The  cholesterinized  antigen  gives  some  degree  of  a  positive  reaction  in 
5  per  cent,  of  known  non-syphilitic  cases.  With  some  observers  this  discrepancy 
reaches  as  high  as  ten  per  cent. 

RECOGNITION  OF  THE  ORGANISM  OF  SYPHILIS 
From  the  clinical  standpoint,  for  the  purpose  of  establishing  the  diagnosis, 
the  Treponema  pallidum,  or  Spirochccta  pallida  (according  to  whether  the  or- 
ganism is  considered  a  protozoon  or  a  bacterium),  may  be  sought  for  in  the 
chancre  and  in  the  secondary  eruptions  of  the  skin  and  accessible  mucous 
membranes.  They  appear  as  fine,  closely,  and  regularly  coiled  spirals.  Their 
extreme  variations  in  length  are  from  4  to  24  microns,  the  usual  length  being 
between  7  and  10  microns;  the  number  of  twists  varies  from  3  to  30,  the  usual 
number  being  about  12.  The  organism  is  actively  motile,  the  movements  being 
described  as  of  four  kinds^ — a  rotary  motion  on  the  long  axis  of  the  spiral, 
a  bending  of  the  filament,  contraction  and  extension  of  its  spirals,  and  progres- 
sion through  the  medium  in  which  it  lies.  The  regularity  of  the  undulations  is 
quite  characteristic,  whether  the  organism  is  living  or  dead;  stained  specimens, 
however,  are  apt  to  be  slightly  less  regular  in  this  respect  than  are  the  living 
organisms. 

Failure  to  discover  the  organisms,  particularly  in  greatly  indurated  chancres, 
and  those  which  have  been  treated  with  caustics,  is  not  rare,  so  that  single, 
and  even  repeated,  negative  examinations  are  only  relatively  diagnostic;  should 
the  lesion  be  clinically  syphilitic,  repeated  Wassermann  reactions  should  be 
performed  in  addition. 

The  examination  may  be  made  by  means  of  dark-ground  illumination,  by 
Burri's  India-ink  method,  or  by  means  of  stained  smears,  the  methods  being 
mentioned  in  the  order  of  preference.  Whichever  is  chosen,  the  material  should 
be  collected  from  the  depths  of  the  lesion,  the  secretion  on  the  surface  not 
being  satisfactory.  This  is  best  done  in  the  case  of  ulcers  by  washing  off 
the  surface  with  salt  solution  and  then  squeezing  the  lesion  till  a  drop  of 
serum  appears;  the  serum  may  most  easily  be  transferred  to  the  slide  by  means 
of  a  capillary  pipette.  When  there  is  no  ulceration  the  epithelium  may  be 
gently  scarified  and  serum  expressed,  or  a  vesicant  may  be  applied  and  the 
serum  used;  as  blood  and  pus  interfere  with  the  examination  by  obstructing 
the  view,  these  should  be  eliminated  as  far  as  possible.  To  prevent  infection, 
the  surgeon's  thumb  and  forefinger  should  be  protected  by  rubber  finger-cots, 
or  the  squeezing  may  be  done  by  the  patient. 


856  GEXITO-URINARY  SURGERY* 

Dark-ground  illumination  is  effected  by  means  of  a  special  substage,  at- 
tachable to  any  microscope,  whereby  the  rays  of  light  are  made  to  fall  upon 
the  object  obliquely,  so  that  only  those  rays  which  are  refracted  by  particles 
in  the  field  reach  the  eye.  By  this  means  it  is  possible  to  see  such  bodies 
as  the  Treponema  pallidum,  whose  refractive  index  is  so  nearly  the  same  as 
that  of  water  that  by  ordinary  illumination  they  are  invisible.  A  drop  of  cedar 
oil  must  be  placed  between  the  condenser  and  the  slide;  the  oil  immersion  is 
the  best  objective  for  the  examination.  The  sun,  a  nitrogen-filled  "stereopti- 
con"  Mazda  lamp  (100  to  250  watts),  or  a  small  arc  may  be  used  as  the 
illuminant.  Viewed  by  this  method,  the  syphilitic  organism  appears  as  a  white 
spiral  on  a  black  background.  Its  distinguishing  characteristics  are  the  slow- 
ness of  its  movements,  it  being  very  easy  to  keep  it  in  the  field;  the  regularity 
of  its  spirals;  its  tenuity,  and  its  white  color,  certain  other  spirochsetes  having 
a  yellowish  hue,  or  even  a  reddish  tint  when  slightly  out  of  focus.  The 
Spirochccta  rejringens,  most  often  found  associated  with  the  pallida,  is  a  longer, 
heavier  organism,  and  less  regular  in  its  undulations.  Spirochccta  gracilis  is  not 
quite  so  slender  as  pallida,  not  quite  so  regular  in  its  undulations,  and  a  little 
more  vigorous  in  its  movements;  in  the  mouth  Spirochccta  dentium  may  be  a 
cause  of  error,  but  the  fact  that  it  is  only  about  half  the  size  of  pallida  should 
serve  to  differentiate  them. 

BuRRi's  Method. — A  drop  of  Giinther- Wagner's  Chinese  water-proof  ink 
is  mixed  with  a  drop  of  the  suspected  serous  exudate  at  one  end  of  a  slide, 
and  spread  after  the  manner  of  spreading  a  blood  film  by  means  of  the  end 
of  another  slide.  (To  be  entirely  satisfactory,  the  ink  should  be  sterilized 
and  centrifugalized.)  When  dry,  a  drop  of  cedar  oil  is  applied,  and  the 
slide  is  examined  with  the  immersion  objective.  As  the  ink  does  not  penetrate 
the  spirochaetes,  these  appear  as  deUcate,  white,  undulating  threads  on  a 
granular  black  background.  Treated  in  this  way,  pallida  does  not  straighten 
out  as  do  most  of  the  other  spirochaetes,  but  it  is  harder  to  judge  its  thick- 
ness than  by  dark-ground  illumination,  and  the  characteristic  movements  are, 
of  course,  lost.     Five  per  cent,  collargol  may  be  used  in  place  of  the  ink. 

Stained  Smears. — The  Spirochccta  pallida  is  stained  with  considerable 
difficulty,  so  that  for  this  reason,  and  because  it  is  time-consuming,  this  method 
is  not  recommended  for  purposes  of  diagnosis.  Moreover,  there  may  be  some 
distortion  of  the  filament  in  the  process  of  fixing,  so  that  it  is  more  difficult 
to  determine  the  nature  of  the  organism.  One  of  the  best  methods  is  that 
of  Giemsa;  the  stain  may  be  most  conveniently  prepared  from  the  tablets 
of  the  Burroughs-Wellcome  Company.  By  this  method  the  pallida  has  a  pink 
hue,  while  other  spirochaetes  are  a  pale  blue  (Plate  XX).  Tribondeau's  modifi- 
cation of  Fontana's  staining  method  is  thus  described  by  Harrison;  "A  thin 
film  of  the  secretion,  as  free  from  blood  as  possible,  is  spread  on  a  slide  and 
allowed  to  drv.  It  is  covered  repeatedly  for  about  a  minute  with  the  following 
(Huge's)   solution: 

Pure  acetic  acid 1 

Formalin,  40  per  cent 2 

Distilled    water 100 


PLATE  XX 


Smear  from  chancre,  stained  with  eosin-azur,  by  Leishman's  method.  The  commercial  tablet 
(Burroughs,  Wellcome  &  Co.)  is  dissolved  in  10  c.c.  of  pure  methyl  alcohol.  A  few  drops  are  placed 
on  the  air  dried  film  one  to  two  minutes,  then  double  the  number  of  drops  of  distilled  water  are  added 
and  staining  continued  for  five  minutes  longer.  The  film  is  then  rinsed  in  distilled  water,  dried  and 
mounted  and  examined  under  an  oil  immersion  lens.  Observe  that  the  organism,  P,  of  almost 
immeasurable  thinness  and  regular  undulations,  is  the  Treponema  pallidum  (Spirochmta  pallida): 
that,  R,  with  the  irregular  spirals,  also  broader  and  more  easily  seen,  is  the  Spirochceta  refringens. 
The  Treponema  pallidum  measures  from  4  to  24  microns  in  length  and  averages  about  0.25  micron 
in  thickness.  It  possesses  from  3  to  30,  usually  8  to  12,  spirals  or  undulations,  characterized  by  their 
regularity.  In  morphology  the  organism  resembles  a  tiny  corkscrew  with  distinctly  pointed  ends. 
The  Spirochceta  pallida  is  actively  motile  and  characterized  by  four  different  movements:  a  rotary; 
a  lateral  or  wavy  motion;  progression  forward  or  backward  in  the  medium  in  which  it  lies,  and  a 
contraction  and  extension  of  the  spirals.  The  Spirochmta  pallida  has  been  found  in  every  lesion 
of  syphilis,  and  is  readily  demonstrable  in  chancres  and  mucous  patches,  either  by  dark  field  illumi- 
nation or  stained  smear.  In  tertiary  manifestations,  it  is  best  demonstrated  in  the  tissue  by  the 
method  of  Levaditi.  It  can  be  grown  in  pure  culture,  and  certain  of  the  lower  animals,  notably 
the  chimpanzee,  have  been  successfully  inoculated. 


THE  LABORATORY  DIAGNOSIS  OF  SYPHILIS  857 

To  complete  fixation  alcohol  is  dropped  on  the  slide  and  then  flamed.  The 
following  mordant  is  then  applied: 

Tannic  acid 5 

Distilled    water     100 

warming  gently  till  steam  rises,  and  then  allowing  to  act  for  30  seconds  longer. 
The  specimen  is  washed  under  the  tap  for  a  few  seconds,  the  excess  water 
thrown  off,  and  the  slide  then  covered  with  Fontana's  solution,  which  is  pre- 
pared as  follows:  To  a  5  per  cent,  silver  nitrate  solution  ammonia  is  added, 
drop  by  drop,  with  a  capillary  pipette  till  a  sepia  precipitate  forms  and  redis- 
solves.  To  this  solution  more  5  per  cent,  silver  nitrate  is  added  till  a  solu- 
tion is  produced  which  remains  slightly  cloudy  on  shaking.  The  slide  is  cov- 
ered with  this  solution,  and  gently  warmed  till  steam  arises;  the  solution  is 
then  allowed  to  act  for  30  seconds  longer." 

Stained  in  this  way,  spirochaetes  appear  dark  brown  to  black.  Such  speci- 
mens fade  in  a  few  days  under  cedar  oil  or  Canada  balsam. 

THE   LUETIN   REACTION 

This  is  an  allergic  reaction  produced  by  the  intradermal  injection  of  a 
substance  called  luetin,  an  emulsion  of  killed  treponemata.  After  sterilization 
of  the  skin  one  or  two  injections  of  0.07  c.c.  of  luetin  are  made,  usually  into 
the  left  arm.  As  a  control,  the  other  arm  is  similarly  injected  with  an 
emulsion  of  culture  medium.  A  very  fine  needle  should  be  used  to  deposit  the 
emulsion  just  beneath  the  epidermal  layer,  between  this  and  the  cutis  vera. 

Negative  Reaction. — Noguchi  states  that  in  the  majority  of  normal  per- 
sons after  twenty-four  hours  there  appears  at  the  site  of  the  inoculation  a 
small,  erythematous  area,  which  disappears  within  forty-eight  hours,  leaving 
no  induration.  Occasionally,  after  a  day  or  two,  a  small  papule  may  form, 
which  begins  to  recede  in  three  days  and  leaves  no  induration. 

Positive  Reaction. — Positive  reactions  may  take  the  papular,  pustular,  or 
torpid  forms.  The  papular  reaction  (Plate  XXI)  is  characterized  by  a  large, 
elevated,  indurated  papule,  from  five  to  ten  millimetres  in  diameter,  appearing 
in  twenty-four  to  forty-eight  hours.  It  may  be  surrounded  by  a  distinct  zone 
of  redness  and  exhibit  marked  telangiectasis.  The  size  and  induration  of  the 
lesion  increase  for  three  or  four  days,  after  which  the  inflammation  subsides. 
The  color  of  the  papule  gradually  becomes  a  dark-bluish  red;  the  induration 
usually  disappears  within  a  week.  The  pustular  reaction  is  similar  to  the  above 
until  the  fourth  or  fifth  day,  when  the  papule  becomes  oedematous  and  may 
exhibit  multiple  miliary  vesicles.  Central  softening  occurs,  and  within  twenty- 
four  hours  the  papule  is  transformed  into  a  vesicle,  becoming  definitely  pustular. 
The  pustule  soon  ruptures  and  the  sore  becomes  covered  by  a  crust,  which 
falls  off  in  a  few  days.  This  is  the  reaction  most  frequently  observed  in  tertiary 
and  treated  secondary  and  hereditary  syphilis.  In  the  torpid  reaction,  rarely 
observed,  the  phenomena  at  the  site  of  injection  fade  away  in  three  or  four 
days,  but  become  relighted  into  a  typical  pustular  reaction  after  ten  or  more 
days.  Slight  constitutional  symptoms  are  noticed  for  twenty-four  hours  in 
most  positive  cases. 


858  GENITO-URINARY  SURGERY 

The  reaction  becomes  positive  later  than  the  Wassermann,  and  is  not  so 
responsive  to  the  changes  brought  about  by  treatment.  It  is  claimed  that  it 
is  especially  valuable  in  those  latent  and  late  cases  in  which  the  Wassermann 
so  often  fails.  This  claim  has  not  been  largely  substantiated.  There  are  ap- 
parently many  positive  reactions  in  nonsyphilitic  cases. 

The  administration  of  iodine  renders  the  luetin  reaction  positive  in  normal 
individuals.  The  test  is  therefore  totally  unreliable  in  patients  who  have 
recently  taken  this  element  in  any  form. 

EXAMINATION  OF  THE  CEREBROSPINAL  FLUID 

Test  for  Globulin  in  the  Cerebrospinal  Fluid 
In  syphilitic  disease  of  the  cord  and  brain  an  excess  of  globulin  is  usually 
present  in  the  fluid.  This  may  be  recognized  by  the  butyric  acid  test  of 
Noguchi.  Four-tenths  of  a  cubic  centimetre  of  a  ten  per  cent,  solution  of 
butyric  acid  is  added  to  0.1  c.c.  of  cerebrospinal  fluid.  This  is  boiled  for  a 
moment,  0.1  c.c.  normal  sodium  hydrate  added,  again  boiled  momentarily,  and 
set  aside  for  observation.  The  reaction  is  read  after  ten  or  twenty  minutes; 
positive  (that  is,  with  an  excess  of  globulin  present)  if  the  fluid  contains  a 
coarse  granular  or  fiocculent  precipitate;  negative  (normal)  if  there  is  merely 
a  slight  opalescence  or  a  slight  sandy  precipitate.  If  the  reaction  is  ambiguous 
it  should  be  repeated,  using  double  the  quantity  of  fluid. 

The  Ross-Jones  and  Pandy  tests  have  the  advantages  of  being  odorless, 
reliable,  and  sensitive.  The  former  is  performed  by  overlaying  a  solution  of 
ammonium  sulphate  saturated  at  the  boiling-point  with  a  layer  of  cerebrospinal 
fluid.  In  the  presence  of  a  globulin  excess  a  white  ring  forms  at  the  line  of 
contact.  The  Pandy  test,  slightly  more  delicate  than  the  Ross- Jones,  consists 
in  adding  one  drop  of  the  fluid  to  1  c.c.  of  a  saturated  aqueous  solution  of 
phenol.  The  formation  of  a  bluish- white  ring  or  cloud  indicates  globulin 
excess. 

Cytological  Examination 
In  syphilitic  diseases  of  the  cord  and  brain  there  is  more  or  less  marked 
increase  in  the  number  of  lymphocytes  present.  Polymorphonuclear  leucocytes 
are  not  found.  The  freshly  drawn  fluid  may  be  counted  in  any  of  the  blood- 
counting  chambers,  but  best  in  one  of  the  larger  ones,  as  that  of  Rosenthal. 
Counts  of  under  5  to  the  cubic  millimetre  may  be  considered  as  normal; 
counts  from  6  to  9  as  doubtful;  and  counts  over  9  as  positive. 

Lange's   Colloidal   Gold  Test 

Certain  substances  in  abnormal  cerebrospinal  fluids  are  capable  of  causing 
a  "coagulation"  or  precipitation  of  solutions  of  colloidal  gold,  so  that  these 
solutions  become  more  or  less  completely  decolorized.  Moreover,  the  dflutions 
of  the  cerebrospinal  fluid  in  different  diseases  react  differently,  so  that  by 
using  a  series  of  dilutions  more  or  less  typical  "curves"  can  be  plotted. 

The  nature  of  the  substance  or  substances  causing  the  reaction  has  not 
been  determined- 


THE  LABORATORY  DIAGiXOSlS  OF  SYPHILIS  859 

The  method  of  applying  the  test  is  simple;  unfortunately,  the  preparation 
of  the  reagent  requires  the  greatest  care,  and  is  attended  with  so  much  diffi- 
culty that  a  number  of  men  have  been  quite  unable  to  prepare  satisfactory 
solutions.-  For  the  test  a  series  of  11  test-tubes  is  used.  In  the  first  of  these 
L8  c.c.  of  fresh  0.4  per  cent,  sodium  chloride  solution  is  placed;  in  each  of 
the  remaining  tubes  1  c.c.  of  the  same  solution.  To  the  first  tube  is  then 
added  0.2  c.c.  cerebrospinal  fluid.  After  thorough  mixing,  1  c.c.  is  withdrawn 
and  added  to  the  second  tube,  the  process  being  repeated  with  all  the  tubes 
except  the  eleventh,  which  is  used  as  a  salt  solution  control.  The  dilutions 
therefore  run  from  1-10  to  1-5120.  Five  cubic  centimetres  of  the  reagent, 
colloidal  gold,  are  then  added  to  each  tube,  and  the  series  set  aside  till  the 
following  day  for  final  reading.  It  is  customary  to  indicate  the  changes  in 
the  color  of  the  solution  by  numerals  from  0  to  5,  0  representing  an  absence 
of  all  change,  and  5  complete  decolorization;  the  "curve"  then  is  indicated 
by  a  series  of  ten  numerals,  as  5555542100  (typical  paretic  curve),  0123310000 
(luetic  curve),  0001123531  (curve  of  meningitis,  with  greatest  intensity  in  the 
higher  dilutions).  0000000000   (curve  of  normal  fluid). 

^For  details  of  preparation  see  article  of  Miller,  Brush,  Hammers,  and  Felton, 
Bulletin   of  Johns  Hopkins  Hospital,   1915,  xxvi,   p.   391. 


CHAPTER  XLIV 
THE  TREATMENT  OF  SYPHILIS 

The  treatment  of  syphilis  is  conveniently  considered  under  the  following 
heads: 

1.  Prophylactic. 

2.  Abortive. 

3.  Constitutional. 

4.  Local. 

PROPHYLACTIC  TREATMENT 

A  disease  which  owes  its  origin  to  a  pathogenic  organism  which  with  few 
exceptions  is  carried  by  direct  contact  and  usually  during  sexual  approach, 
is,  theoretically,  entirely  preventable. 

The  various  Contagious  Diseases  Acts  represent  the  attempts  of  the  gov- 
erning authority  to  protect  the  community  at  large  from  disease  and  infec- 
tion by  regulating  the  hygiene  of  and  placing  restrictions  on  the  class  most 
liable  to  spread  the  disease.  These  measures  have  been  of  great  benefit, 
and  it  has  been  shown  that  clandestine  prostitution,  out  of  reach  and  control 
of  these  acts,  is  the  major  source  of  contagion  in  the  countries  in  which  such 
acts  have  been  in  force. 

No  method  has  as  yet  been  devised  which  is  in  all  respects  unobjection- 
able or  is  capable  of  universal  application.  In  the  details  of  every  plan  yet 
proposed  there  has  been  much  that  was  defective  or  positively  harmful.  The 
subject  is  still  one  of  the  unsolved  sanitary  problems  of  the  age.  The  direc- 
tion in  which  action  must  be  taken,  and  the  general  character  of  that  action, 
may,  nevertheless,  be  indicated,  if  not  demonstrated. 

We  may  begin  by  urging  the  necessity  of  a  more  general  and  more  accurate 
public  knowledge  concerning  the  gravity  and  the  prevalence  of  this  disease. 
The  innocent — who  are  also  in  this  respect  the  ignorant — members  of  the 
community  have  claims  which  we,  who  seek  to  fulfil  the  highest  function  of 
our  profession — the  preservation  of  health,  individual  and  national — cannot 
conscientiously  disregard. 

Every  adult  citizen  should  be  aware  for  his  own  sake  of  the  possibilties 
of  contamination  which  surround  him;  every  parent  should  be  competent  to 
protect  his  wife  or  children  from  all  indirect  infection  through  a  servant  or 
playmate,  a  household  utensil  or  a  toy;  every  wife  should  know  that  by  per- 
mitting the  approaches  of  a  syphilitic  husband  she  herself  becomes  liable  to 
disease,  and  to  the  creation  of  a  being  which  has  few  chances  for  life  and  still 
fewer  for  health  and  happiness;  and  every  syDhilitic  should  realize  that,  except 
after  certain  intervals  and  under  proper  restrictions,  his  marriage  is  an  outrage 
to  the  woman  he  professes  to  love  and  a  crime  against  society. 

Once  let  these  facts  be  clearly  understood  and  this  information  widely 
diffused,  and  an  important  step  will  have  been  taken  not  only  in  preventing 
860 


THE  TREATMENT  OF  SYPHILIS  861 

accidental  and  guiltless  contagion,  but  also  in  preparing  public  opinion  for 
the  legislative  measures  which  are  believed   to  be  desirable. 

For  these  reasons  we  should  in  every  proper  way  encourage  the  presenta- 
tion of  this  matter  to  the  community  at  large,  by  means,  for  example,  of 
discussions  in  health  societies,  by  proper  representations  to  editors  of  the  daily 
press,  and  by  careful  but  truthful  and  forcible  statements  to  our  friends  and 
patients,  who  are  frequently  eager  for  information  on  the  subject. 

It  may  be  admitted  at  once  that  if  the  total  abolition  of  prostitution 
could  be  accomplished,  and  if  it  could  be  followed  by  the  coriversion  of  the 
army  of  harlots  into  peaceful  housekeepers  or  sisters  of  charity,  and  the  trans- 
formation of  their  male  patrons  into  pure,  law-abiding  citizens  and  fathers 
of  families,  it  would  be  a  most  satisfactory  consummation.  No  one,  however, 
at  the  present  day,  with  perhaps  the  exception  of  a  few  impractical  clergymen 
and  a  number  of  enthusiastic  and  well-meaning  but  misguided  women,  believes 
in  the  possibility  of  attaining  such  an  end.  The  accumulated  experience  of 
mankind  constitutes  a  wall  of  unanswerable  argument.  All  attempts  at  the 
extinction  of  prostitution  present  throughout  the  centuries  one  unbroken  record 
of  failure.  Wherever  this  scheme  has  been  tried,  the  sexual  impulse,  the 
strongest  to  which  human  nature  is  subject,  has  asserted  itself,  and  other  laws 
have  been  violated,  other  and  graver  evils  have  resulted.  The  remedy  has 
proved  worse  than  the  disease  (Lecky).  Seduction,  illegitimacy,  criminal 
abortion,  and  infanticide  have  invariably  followed,  and  the  total  average  mor- 
tality of  the  community  has  been  seriously  increased. 

In  considering  the  necessity  for  general  prophylaxis  and  the  direction  which 
efforts  towards  the  accomplishment  of  this  end  should  take,  it  should  be  re- 
membered : 

1.  That  syphilis  is  of  great  antiquity  and  is  likely  to  continue  indefinitely. 
2,  That  this  disease  already  affects  a  large  number  of  the  population  (5  per 
cent.),  and  that  by  means  of  its  many  forms  of  inoculation  and  transmission 
it  is  rapidly  spreading  still  farther.  3.  That  the  existing  means  for  its  treat- 
ment among  the  poorer  classes  are  insufficient,  and  that  the  establishment  of 
institutions  for  that  purpose  or  the  endowment  of  special  wards  in  our  gen- 
eral hospitals  is  a  measure  eminently  worthy  of  the  attention  of  the  public- 
spirited  and  benevolent.  4.  That  its  most  common  mode  of  propagation  is 
by  irregular  or  illicit  sexual  intercourse,  and  that  therefore  we  should  turn  our 
main  efforts  at  prevention  in  this  direction,  while  endeavoring  at  the  same  time 
and  in  every  decent  and  proper  manner  to  guard  the  community  at  large 
from  the  effects  of  ignorance.  5.  That  prostitution,  arising  in  response  to 
the  demand  for  this  illicit  indulgence,  has,  like  syphilis,  existed  from  time 
immemorial,  and  is  not  likely  to  disappear.  6.  That  prostitutes  themselves 
need  protection  and  have  claims  on  the  humanity  of  the  law.  7.  That  by 
means  of  legislation  the  syphilitic  man  or  woman  may  be  subject  to  a  control 
which  will  promptly  render  him  or  her  incapable  of  transmitting  the  disease 
by  contact  and  reasonably  assure  an  adequate  curative  treatment.  8.  That 
there  is  sufficient  evidence  that  such  control,  though  surrounded  with  difficulties, 
is  possible. 

The  only  certain  method  of  escaping  the  venereal  forms  of  syphilis  is  the 
avoidance  of  exposure.    When  consulted  in  regard  to  prophylaxis  the  physician 


862  GENITO-URINARY  SURGERY 

should  insist  upon  this  point  and  need  not  volunteer  further  information,  though 
under  proper  circumstances  he  should  not  withhold  knowledge  as  to  the  means, 
by  which  the  danger  of  contagion  can  be  lessened,  if  not  entirely  avoided. 

This  danger  can  be  diminished  by  (1)  avoidance  of  intercourse  when  there 
is  an  abrasion  or  any  surface  break  about  the  genitaha;  (2)  the  use  of  covers; 
(3)  the  local  use  of  protective  and  antiseptic  ointments;  (4)  thorough  local 
washings  with  mild  antiseptic  lotions  immediately  before  and  immediately  after 
coitus;  (5)  circumcision  in  persons  with  redundant  or  phimotic  foreskins;  (6) 
the  use  of  astringents  by  those  whose  mucous  membranes  are  particularly  vul- 
nerable; (7)  immediate  antiseptic  applications  to  and  superficial  cauterization 
of  abrasions  acquired  during  coitus.  The  post-exposure  method  of  protection 
which  has  seemed  most  efficacious  is  the  rubbing  of  the  part  with  a  33  per 
cent,  calomel  ointment,  a  small  portion  being  also  placed  within  the  meatus. 
The  inunction  should  be  preceded  by  a  thorough  washing  with  soap  and  water; 
it  is  most  serviceable  when  used  immediately  after  intercourse. 

The  risks  of  extragenital  infection  are  lessened  by  (1)  the  avoidance  of 
prolonged  contact  of  any  portions  of  the  body,  this  particularly  holds  true  of 
the  lips  and  tongue;  (2)  care  as  to  the  cleanliness  of  eating  and  drinking 
utensils,  pipes,  or  any  article  which  is  liable  to  be  contaminated  by  the  dis- 
charge from  the  lesions  of  syphilitics;  (3)  the  immediate  cauterization  of  any 
abrasion  or  wound  which  could  possibly  have  been  infected  by  the  discharges 
from  syphilitic  lesions. 

Perhaps  the  most  important  means  of  prophylaxis  is  thoroughly  to  impress 
upon  those  who  are  suffering  from  florid  syphilis  the  fact  that  any  of  the 
body  secretions  may  carry  the  contagion.  They  must  be  instructed  as  to 
the  possibility  of  infecting  others  from  cigars,  spoons,  forks,  or  other  articles 
moistened  with  their  saliva,  or  from  razors,  manicure  instruments,  scissors, 
or  knives  which  may  be  stained  by  their  blood,  and  from  handkerchiefs,  sheets, 
pillow-cases,  garments,  towels,  sponges,  or  baths  which  may  contain  the  virulent 
discharge  from  mucous  membrane  or  skin  lesions. 

The  danger  of  conveying  the  contagion  by  kissing,  by  intercourse,  or  by 
body  contact  of  any  kind  must  be  clearly  laid  down. 

In  the  case  of  a  surgeon,  accoucheur,  or  dentist,  the  possibility  of  in- 
fecting patients  by  means  of  the  blood  incident  to  accidental  wounds  of  the 
hands  must  be  duly  considered;  indeed,  this  danger  is  sufficiently  pronounced 
to  forbid  the  performance  of  difficult  or  extensive  operations  during  the  florid 
stage  of  the  disease. 

As  further  means  of  prophylaxis,  barbers,  masseurs,  chiropodists,  all  whose 
occupation  requires  them  to  treat  the  skin  and  its  appendages  by  instruments 
or  by  the  hands,  should  be  thoroughly  instructed  as  to  the  possibility  of  con- 
veying the  disease.  They  should  be  required  to  sterilize  their  instruments  by 
heat  or  other  efficient  means  before  using  them  on  each  new  client,  and  should 
be  held  legally  responsible  for  cases  of  syphilis  which  develop  in  consequence 
of  their  ignorance  or  neglect  of  simple  precautions. 

Any  community,  state,  or  nation  can  lessen  the  incidence  of  syphilis  to 
the  vanishing  point  by — 

1.  Making  the  disease  a  reportable  one. 


THE  TREATMENT  OF  SYPHILIS  863 

2.  Holding  criminally  responsible  those  who  transmit  it. 

3.  Keeping  under  supervision  or,  when  needful,  under  confinement  those 
capable  of  transmitting  it  until  treatment  rendering  them  harmless  to  the  com- 
munity has  been  applied. 

Laws  passed  to  this  effect  are,  of  course,  futile  and  corrupting  unless  they 
be  supported  by  the  determined  backing  of  the  people,  and  particularly  of  the 
medical  profession. 

THE  ABORTIVE  TREATMENT 

ine  two  memoas  proposeu  tor  the  abortion  of  syphilis  immediately  upon 
the  appearance  of  chancre  are — 

1.  The  excision  or  complete  destruction  of  the  chancre  and  the  surround- 
ing tissues. 

2.  Destruction  of  the  specific  virus  by  immediate  active  constitutional 
treatment. 

Excision  or  Destruction  of  the  Chancre. — The  abortion  of  syphilis 
by  excision,  cauterization,  or  injection  of  the  chancre  has  been  attempted  in 
many  hundreds  of  cases,  but  efforts  in  this  direction  have  proved  futile. 

Aside  from  the  attempt  to  abort  syphilis,  excision  of  the  chancre  may  be 
undertaken  with  the  idea  of  ridding  the  system  of  a  focus  of  infection,  or 
for  cosmetic  or  other  reasons,  and  if  total  excision  does  not  leave  a  deform- 
ing or  crippling  scar  it  is  a  desirable  procedure.  The  ulceration  of  chancre, 
even  though  it  appear  extensive  and  deep,  usually  disappears  under  consti- 
tutional treatment,  leaving  an  insignificant  scar. 

When  the  sore  is  so  situated  that  its  removal  by  the  knife  would  cause 
troublesome  hemorrhage,  deformity,  or  interference  with  function,  constitutional 
treatment  should  be  relied  upon  to  effect  its  cure. 

Even  though  the  sore  has  not  been  seen  for  one  or  two  weeks  and  the 
inguinal  glands  are  typically  enlarged,  if  situated  upon  a  surface  from  which 
it  can  be  removed  without  resulting  deformity,  it  should  be  excised,  the  result- 
ing wound  being  sutured.  When  situated  entirely  on  the  foreskin,  whether 
seen  early  or  late  in  its  development,  total  removal  by  circumcision  is  desir- 
able. 

Constitutional  Abortive  Treatment. — The  more  prompt  and  vigorous 
the  treatment  with  arsenic  and  mercury  the  more  assured  the  clinical  cure  of 
the  disease  (see  pp.  866  and  870).  Hence  treatment  should  be  given  as  soon  as 
the  diagnosis  of  syphilis  is  made.  The  probable  diagnosis  is  made  on  the  history 
and  the  clinical  findings,  the  absolute  diagnosis  is  based  on  finding  the  trepo- 
nema  pallidum. 

THE  CONSTITUTIONAL  TREATMENT  OF   SYPHILIS 

General  Hygienic  Treatment. — The  general  health  of  the  patient  should 
be  carefully  regulated.  He  must  be  warned  as  to  the  importance  of  avoiding 
overwork,  mental  strain,  undue  exposure,  and  excesses  of  all  kinds.  He  should 
eschew  strong  alcoholic  drinks,  but  need  not  be  prohibited  from  moderate 
indulgence  in  light  wines  at  meals.     He  should  be  cautioned  that  the  use  of 


354  GENITO-URINARY  SURGERY 

tobacco  distinctly  predisposes  to  lesions  of  the  mouth  and  throat,  and  should 
be  advised  to  give  up  the  use  of  this  drug  in  all  its  forms. 

The  hereditary  tendencies  and  diathesis  of  each  individual  should  be  studied, 
since  every  depressing  influence  by  lessening  cell-resistance  may  lead  to  in- 
creased virulence  of  the  disease.  Tuberculosis  in  the  form  cHnically  recog- 
nized as  struma  particularly  favors  virulent  manifestations  of  syphilis,  such 
as  deep  and  obstinate  ulceration,  ostitis,  caries,  and  various  visceral  changes. 
A  tuberculous  family  history  should,  therefore,  be  regarded  as  a  special  indica- 
tion for  hygienic  precautions.  A  patient  with  such  a  history  should  avoid  all 
causes  of  local  congestion,  such  as  chilling  of  the  surface,  and  particularly 
should  guard  against  bruises,  sprains,  or  other  traumatisms,  slight  in  them- 
selves, but  strongly  predisposing  to  the  local  development  of  strumous  and  of 
sj^hilitic  lesions.  The  diet  should  be  rich,  of  digestible  fats,  and  carbohydrates. 
Pulmonary  gymnastics  should  be  employed,  and  to  the  specific  treatment  should 
be  added  emulsions  of  partly  digested  cod-liver  oil  in  combination  with  ferrous 
iodide  or  the  hypophosphites. 

Both  the  gouty  and  the  rheumatic  diathesis  exert  a  distinctly  unfavorable 
influence  on  the  course  of  syphilis.  They  predispose  to  vascular  degeneration, 
to  cerebral  disease  secondary  to  endarteritis,  to  troublesome  papulo-squamous 
syphilides,  to  iritis,  to  periosteal  nodes,  and  various  other  affections  of  the 
fibrous  tissue.  The  diet  of  such  patients  should  be  most  carefully  regulated. 
They  should  be  told  to  eat  sparingly  of  dark  meats  and  of  sugars,  to  drink 
freely  of  potash  or  lithia  waters,  and  to  eschew  sweet  wines,  malt  liquors,  etc. 
In  combination  with  the  above  treatment,  short  courses  of  salicylates  may  be 
advantageously  employed,  and  the  iodides  should  be  begun  much  earlier  than 
in  the  case  of  previously  healthy  patients. 

Patients  of  a  neurotic  type  seem  to  be  especially  predisposed  to  affections 
of  the  brain  and  spinal  cord.  The  preliminary  advice  to  such  cases  must 
be  directed  to  the  avoidance  of  mental  strain  of  any  kind.  Every  effort  should 
be  made  to  prevent  that  state  of  nervous  depression  which  the  knowledge  of 
having  contracted  syphilis  so  often  occasions.  Rest  to  the  mind,  and  diversions 
of  various  kinds,  particularly  those  which  require  mild  exercise  in  the  open 
air,  should  be  advised.  Periods  of  rest  are  particularly  desirable.  The  specific 
treatment  may  be  advantageously  supplemented  by  strychnine  and  the  hypo- 
phosphites. 

In  all  patients,  whether  robust  or  weak,  the  hygiene  of  the  mouthy  of  the 
gastro-intestinal  tract,  and  of  the  skin  should  receive  particular  attention,  and 
invariably  repeated  examinations  of  the  urine  should  be  made  to  determine 
whether  or  not  the  kidneys  can  be  depended  on  for  the  elimination  of  arsenic, 
mercury,  and  the  toxic  products  of  the  syphilitic  virus. 

The  teeth  should  be  put  in  perfect  order  by  a  competent  dentist,  and  should 
be  kept  scrupulously  clean  through  the  entire  course  of  treatment  by  cleansing 
washes,  astringent  mildly  antiseptic  powders,  and  careful  removal  of  particles 
of  food  by  means  of  toothDicks  and  dental  floss  immediately  after  eating. 
Upon  the  health  of  the  mucous  membrane  of  the  mouth  depends  to  a  great 
extent  the  ability  of  the  patient  to  take  an  efficient  quantity  of  mercury  with- 
out causing  salivation. 


THE  TREATMENT  OF  SYPHILIS  865 

The  gastro-intestinal  tract  must  be  kept  free  from  irritation  by  well- 
regulated  diet,  by  digestive  and  antiseptic  powders,  and  by  mild  laxatives  when 
indicated.  Only  when  the  stomach  and  bowels  are  in  good  condition  can  the 
full  dose  of  the  specific  drugs  be  absorbed  and  eliminated  without  exciting 
symptoms  of  gastro-intestinal  catarrh. 

The  skin  aids  in  eliminating  mercury.  It  should  be  kept  in  perfect  health 
by  daily  bathing  and  friction,  hot  or  cold  water  being  employed  in  accord- 
ance with  the  feelings  of  the  patient.  Hot  plunge  baths,  Turkish  baths,  and 
hot-air  baths  are  to  be  advised,  unless  marked  vascular  degenerations  contra- 
indicate  their  employment. 

The  best  indication  of  a  patient's  general  health  is  his  aptitude  for  work 
or  play,  and  his  enjoyment  thereof,  his  digestion,  sleep,  and  the  maintenance 
of  his  normal  weight. 

Specific  Treatment. — This  is  administered  in  as  full  doses  as  the  patient 
can  tolerate  without  prejudice  to  general  health;  the  dose  is  regulated  by  the 
patient's  susceptibility.  The  development  of  syphilitic  lesions,  even  in  the 
absence  of  a  positive  Wassermann,  is  indicative  of  inadequate  dosage.  The 
entire  absence  of  lesions,  a  condition  of  general  good  health,  and  a  persistently 
negative  Wassermann,  are  indicative  of  a  proper  dosage.  Loss  of  weight  and 
general  malaise  may  be  indicative  of  either  too  much  or  too  little  specific 
treatment.  The  gauge  of  efficient  treatment  is  the  health  of  the  patient.  Fre- 
quently, as  a  result  of  treatment,  there  is  an  increase  in  general  health,  markedly 
beyond  the  degree  enjoyed  before  syphilitic  infection. 

SYSTEMATIC    TREATMENT    OF    SYPHILIS 

The  general  hygienic  treatment  already  described  (pp.  863  to  865)  is  inau- 
gurated at  once;  in  addition,  the  patient's  weight  is  recorded  and  repeated 
quantitative  and  qualitative  examinations  of  the  urine  are  made. 

Arsenic  and  mercury  should  be  given  at  once,  usually  in  this  order,  re- 
gardless of  the  stage  or  age  of  the  disease. 

The  always  late  cardiovascular  lesions  and  some  of  the  nervous  manifesta- 
tions call  for  a  supplementary  course  of  iodides. 

The  dosage  should  be  as  full  as  the  patient  can  take  without  depressing 
him  mentally,  weakening  him  physically,  markedly  increasing  or  diminishing 
his  urinary  output,  producing  toxic  symptoms,  or  lowering  his  weight;  hence 
it  must  be  based  on  a  conservative  guess. 

The  indications  for  conservatism  are  crippled  kidneys  or  liver,  or  both, 
and,  in  the  case  of  the  arsenical  preparations,  an  intense  local  or  general 
spirochsetal  infection,  particularly  of  the  cerebrospinal  system,  under  which 
circumstances  the  treatment  should  be  inaugurated  by  mercury,  on  the  theory 
that  the  salvarsan,  in  its  destruction  of  the  multitudes  of  spirochaetes,  may  liber- 
ate a  lethal  quantity  of  endotoxins. 

Arsenic  given  in  the  form  of  salvarsan  or  neosalvarsan  causes  prompt  dis- 
appearance of  spirochaetes  from  a  primary  or  secondary  lesion;  hence  it  renders 
them,  in  the  course  of  a  few  hours,  noncontagious.  It  also  causes  their  prompt 
healing,  a  matter  of  a  few  days.  Nor  is  the  effect  upon  infiltrations  which 
55 


866  GENITO-URINARY  SURGERY 

have  not  been  replaced  by  fibrosis  less  marked,  though  the  action  is  neces- 
sarily slower. 

Ihe  immediate  effect  of  arsenic  is  at  times  an  aggravation  of  local  lesions 
expressed  by  an  oedematous  swelling  (Jarisch-Herxheimer  reaction) ;  this  is  also 
observed  after  the  use  of  mercury,  but  less  often,  and  in  milder  form.  Sup- 
plementary to  arsenic,  mercury  is  also  given  in  all  stages  of  the  disease,  the 
combination  being  more  efficacious  than  either  alone.  In  the  late  stages  the 
iodides,  because  of  their  fibrolytic  effect,  are  of  distinct  use,  at  times  curative 
when  other  drugs  fail. 

TREATMENT  WITH  ARSENIC 

Both  salvarsan  and  neosalvarsan  are  dispensed  in  sealed  glass  capsules; 
exposure  to  air  results  in  a  rapid  toxic  decomposition.  Salvarsan  (34  per  cent, 
arsenic),  readily  soluble  in  water,  must,  before  injection,  have  its  acidity  neu- 
tralized. The  addition  of  an  alkali  clouds  the  clear  acid  solution;  further  addi- 
tion results  in  a  clear  alkaline  solution  which  is  injected  into  a  vein,  and 
promptly.  The  water  used  should  be  freshly  distilled,  i.e.,  the  day  of  use. 
The  average  dose  is  0.4  Gm.     (See  method  of  administration,  p.  868.) 

Xeosalvarsan,  a  3-ellow,  water-soluble  powder,  bears  to  salvarsan  in  arsenic 
content  the  ratio  of  2  :  3.  The  average  dose  for  man  is  0.6,  for  woman  0.45, 
for  children  0.1,  for  infants  0.05. 

The  injection,  given  intravenously,  is  prepared  by  dissolving  the  contents  of 
a  capsule  in  water  distilled  the  same  day  in  Jena  glass,  with  precautions  against 
contamination.  The  usual  dilution  has  been  25  c.c.  of  water  for  each  0.15 
gramme  of  neosalvarsan.  There  have  been  no  accidents  fairly  attributable 
to  the  use  of  a  stronger  solution,  0.1  gramme  to  1  or  2  c.c,  and  this  simplifies 
technique  and  lessens  the  occurrence  of  "water  hazards." 

Of  these  two  drugs,  salvarsan  is  perhaps  the  more  popular.  Our  preference 
is  for  neosalvarsan  because  of  the  greater  safety,  greater  ease  of  administra- 
tion, and  what  has  seemed  equal  efficiency.  For  the  technique  of  injection 
see  p.  871. 

The  contra-indications  or  conditions  demanding  conservatism  in  the  employ- 
ment of  arsenical  therapy  by  salvarsan  and  neosalvarsan  or  their  substitutes  are 
haemophilia,  Addison's  disease,  advanced  visceral  disease  tending  to  inevitable 
early  death,  nephritis  (other  than  luetic),  myocarditis,  arteriosclerosis,  aneurism, 
diabetes  and  advanced  disease  of  the  central  nervous  system. 

The  local  after-effects  of  properly  performed  intravenous  injections  are  nil. 
We  have  seen  but  one  case  of  phlebitis,  and  that  symptomless.  Should  either 
of  the  drugs  escape  into  the  subcutaneous  tissues  through  faulty  insertion  of 
the  needle,  or  occasionally  through  leakage  of  the  solution  back  beside  the 
needle,  between  it  and  the  wall  of  the  vein,  the  fact  is  announced  by  the 
severe  pain  suffered  by  the  patient.  When  the  amount  of  fluid  so  misplaced 
is  small,  no  lasting  harm  is  done,  the  cellulitis  subsiding  under  evaporating 
lotions  and  rest ;  when  large,  a  more  or  less  extensive  slough  may  be  produced. 

Systemic  after-effects  from  an  arsenic  injection  are  not  usually  observed, 
aside  from  the  beneficial  one  upon  the  infection.  The  safety  of  the  method 
is  attested  by  its  universal  employment  and  the  few  accidents  reported  there- 


THE  TREATMENT  OF  SYPHILIS  867 

from.  Since  the  use  of  recently  and  properly  distilled  water  as  a  solvent 
the,  at  one  time,  usual  chill,  fever,  and  vomiting,  with  some  days'  depression, 
are  rarely  noted.  Even  with  every  care,  there  will  occur  occasionally  fullness  and 
flushing  of  the  face,  vasomotor  disturbances,  suffocation  sensations,  pain  in  the 
teeth  and  gums,  peculiar  taste  in  the  mouth,  headache,  nausea,  rash  upon  the  skin, 
abdominal  and  lumbar  pain,  slight  jaundice,  the  symptoms  of  acute  gastro-en- 
teritis,  hyper-  or  hypo-secretion  of  urine,  nephritis,  encephalitis;  or  a  depressed 
vital  condition  which  may  persist  for  weeks.  Such  symptoms,  provided  the 
technique  has  been  perfect,  may  be  attributed  to  a  hypersensitiveness  to  arsenic 
or  to  a  breakdown  in  the  usual  detoxicating  process.  They  are  more  com- 
monly noted  after  the  second  or  later  injections  than  after  the  first.  Excep- 
tionally thromboses,  local  or  pulmonary,  and  death  have  been  observed. 

Schamberg  calls  attention  to  the  fact  that  there  is  a  marked  variation  in 
the  toxicity  of  different  lots  of  the  various  arsenical  preparations.  Salvarsan 
and  similar  products  cannot  be  purified  by  repeated  crystallization,  and  for 
this  reason  it  is  probable  that  no  two  lots  are  ever  identical  in  composition. 
The  marketing  of  unduly  toxic  drugs  can  be  avoided  only  by  making  careful 
biological  tests  of  each  lot. 

Of  the  non-German  preparations,  novarsenobenzol  (French),  diarsenol  (Can- 
adian), and  arsphenamine  (Polyclinic)  have  given  best  results. 

In  cases  of  active  cerebrospinal  syphilis,  death  has  resulted  from  a  bloody 
exudate,  with  symptoms  of  acute  meningitis.  Badly  crippled  liver  and  kidneys 
have  developed  anuria.  Under  these  circumstances  the  arsenic,  if  given,  should  be 
administered  in  small  doses. 

The  dosage  of  neosalvarsan,  since  the  original  hope  of  Ehrlich  has  not  been 
realized  {e.g.,  immediate  and  complete  destruction  of  the  invading  microorgan- 
ism), should  be  somewhat  less  than  that  originally  advised  rather  than  more, 
faith  in  its  lasting  effect  being  dependent  upon  repetitions  rather  than  upon 
one  massive  attack.  The  stronger  dosage  has  proved  more  dangerous  and 
has  shown  no  greater  efficiency. 

Given  a  proved  or  suspected  syphilitic  infection,  three  doses  of  neosalvarsan,. 
from  0.45  to  0.9  Gm.,  or  salvarsan,  0.3  to  0.6  Gm.,  are  given  at  weekly  intervals^ 
in  the  absence  of  toxic  symptoms;  if  these  occur  and  are  mild,  the  subsequent  in- 
jection must  not  be  given  for  a  week  or  more  after  these  have  totally  subsided; 
if  they  be  severe,  the  dose  must  be  cut  in  half  and  not  repeated  for  a  month 
or  at  all,  particularly  if  there  be  signs  of  kidney  irritation.  Three  weeks  there- 
after, the  Wassermann  reaction  is  taken,  and  if  positive  another  series  of  three  in- 
jections of  neosalvarsan  or  salvarsan  are  administered  and  so  on  until  the  blood 
test  is  rendered  negative.  In  the  primary  stage  of  syphilis  three  injections  are 
usually  sufficient  to  accomplish  this,  while  in  all  cases  with  strongly  positive  or 
plus,  3  or  4  Wassermann  reactions,  as  in  the  secondary,  intermediate  and  tertiary 
stages  of  the  disease,  from  six  to  twelve  injections  may  be  required  to  render  the 
Wassermann  negative.  Rarely  cases  will  be  encountered,  so-called  "  Wassermann- 
fast"  patients,  in  whom  it  will  be  impossible  to  obtain  a  negative  blood  test.  In 
such  individuals  recourse  must  be  had  to  treatment  with  mercury  and  the  iodides. 

A  psychic  or  physical  persistent  depression  after  injection  calls  for  longer 
intervals,  smaller  doses,  and  a  daily  estimation  of  the  total  quantity  of  urine 


GENITO-URINARY  SURGERY 

passed  in  twenty-four  hours;  arsenic  being  a  vascular  poison  and  manifesting 
its  early  effects  by  polyuria,  its  late  ones  by  anuria. 

Coincident  with  these  injections,  mercury  is  given,  preferably  by  inunction 
or  intramuscular  injection  or  by  mouth  (see  pp.  871  to  874).  This  drug  being 
an  epithelial  poison,  its  early  toxic  effects  upon  the  kidneys  will  be  shown  by 
proteid  and  casts,  hence  urinalyses  must  be  made  for  these  abnormal  elements. 
The  mercury  is  given  for  six,  nine,  or  twelve  days  in  succession  for  four  to 
six  courses,  with  intervals  of  rest  between  each,  half  the  length  of  the  course, 
the  dosage  being  such  that  the  urine  shows  no  abnormality,  the  appetite  is 
good,  and  the  patient's  strength,  cheerfulness,  and  initiative  are  normal.  At 
the  end  of  such  a  treatment  the  patient  will  be  clinically  well.  Nor,  aside  from 
hygienic  living  and  rational  conservation  of  energy,  is  anything  further  needful 
till  the  end  of  six  months,  when  a  Wassermann  is  taken.  Whatever  its  findings, 
the  treatment  should  be  repeated  with  dosage  and  intervals  based  on  previous 
experience,  but  so  planned  as  to  come  well  within  the  patient's  tolerance.  In 
another  six  months  the  treatment  is  repeated  again,  even  if  the  Wassermann 
has  been  both  times  negative,  cutting  the  dose  in  half;  this  can  be  done  by 
lessening  the  number  of  injections  and  inunctions.  After  the  Wassermann 
reaction  of  the  blood  has  been  rendered  negative  by  intensive  treatment  with 
arsenobenzol  (arsphenamine)  administered  in  series  of  three  injections  and  sup- 
plemented by  active  mercurial  treatment,  including  the  iodides  in  the  tertiary 
stage  of  the  disease,  for  one  to  two  years,  forced  treatment  m^  be  suspended, 
providing  in  all  cases  after  the  onset  of  secondaries,  or  with  symptoms  referable 
to  the  central  nervous  system,  or  with  ocular  manifestations  or  in  those  previ- 
ously exhibiting  a  strongly  positive  blood  Wassermann,  the  spinal  fluid  is  also 
found  to  exhibit  a  negative  Wassermann  and  normal  lymphocyte  count.  There- 
after through  life  the  patient  should  take,  spring  and  fall,  for  one  month,  mer- 
cury in  doses  about  two-thirds  those  which  he  took  and  tolerated  in  the  early 
stages  of  his  infection.  Negative  blood  and  spinal  fluid  examinations  must  be 
demanded  indefinitely,  certainly  for  two  or  three  years  after  the  suspension  of 
active  treatment,  before  the  patient  can  be  discharged  tentatively  as  cured  or 
qualified  for  matrimony. 

To  this  general  rule  of  treatment  there  are  exceptions: 

1.  Chancres  seen  early,  that  is,  before  the  advent  of  a  positive  Wassermann, 
treated  intensively  by  salvarsan  or  neosalvarsan  may  be  promptly  cured,  without 
the  aid  of  mercury;  if  seen  late  after  the  Wassermann  has  become  positive,  mer- 
cury in  accordance  with  the  general  principles  outlined  above  should  supplement 
the  arsenobenzol.  Thereafter  treatment  may  be  omitted  if  the  Wassermann  taken 
yearly  for  two  years  is  negative  and  the  patient  remains  free  from  symptoms. 
There  is  reason  to  believe  that  an  early  searching  treatment  radically  cures  most 
of  these  cases. 

2.  The  treatment  should  be  more  intensive  and  more  frequently  repeated  if 
lesions  surely  syphilitic  and  curable  do  not  disappear. 

3.  Cerebrospinal  infections,  or  those  which  are  intense  and  widespread,  may 
contra-indicate  the  use  of  salvarsan  or  neosalvarsan.  Invariably  mercury  and  the 
iodides  are  most  important  in  the  treatment  of  cerebrospinal  syphilis  and  should 
always  supplement  the  arsenic  preparations. 


THE  TREATMENT  OF  SYPHILIS 


869 


4.  Cases  in  which  either  arsenic  or  mercury,  even  in  small  doses,  produces 
toxic  effects  should  be  treated  by  the  one  of  these  drugs  which  is  the  better 
tolerated. 

5.  ^Nlore  harm  than  good  may  be  done  in  old  latent  cases,  evidenced  only  by 
a  positive  Wassermann,  by  resort  to  hyper-intensive  arsenical  treatment. 

The  routine  treatment  of  syphilis  may  be  managed  by  the  adoption  of  one  or 
the  other  of  the  following  outlined  methods: 


Intensive  Arsenical  Treatment  Supplemented  by  Mercury  and  the  Iodides 


Week  of 
treatment 


Wassermann  Negative 

Intravenously 


Primary 


606 
Gm. 


or     914 


Gm. 

0.75 

0.9 

0.9 


1  0.5 

2  0.6 

3  0.6 

Thereafter  blood  to  be  examined  in  three 
weeks,  and  if  negative  at  three  monthly 
periods  for  a  year. 


Week  of 
treatment 

1 

2 
3 
6 


Wassermann  Positiie 

Intravenously 


Gm. 

0.5 
0.6 
0.6 


914 

Gm. 

0.75 

0.9 

0.9 


Wassermann,  and  if  positive 
0.6  0.9 

7  0.6  0.9 

8  0.6  0.9 

11  Wassermann,  and  if  negative 
courses  of  mercury  by  mouth, 
inunction,  or  intramuscularly 
for  six  months.  Thereafter 
blood  to  be  tested  at  three 
monthly  periods  for  a  year. 


Excise  chancre  or  dress  or  .rub  away  with  calomel  ointment. 


Secondary 

Intravenously 
Week  of  606       or     914  ^ 

treatment  Gm.  Gm. 

1  0.5  0.75 

2  0.6  0.9 

3  0.6  0.9 

4  0.6  0.9 

5  0.6  0.9 

6  0.6  0.9 
9  Wassermann,  and  if  positive 

0.6  0.9 

10  0.6  0.9 

11  0.6  0.9 

14  Wassermann,  and  if  negative  ex- 
amination of  spinal  fluid,  and  if 
positive  another  series  of  606  or 
914  until  rendered  negative. 
Thereafter,  mercur\^  in  courses 
by  inimction,  intramuscularly, 
or  by  mouth  for  one  or  two 
years.  Thereafter  blood  tests  at 
three-month  intervals  the  first 
year,  at  six-month  inter\'als  the 
second  year,  and  yearly  there- 
after. The  spinal  fluid  should 
be  examined  yearly  or  as  a  final 
control. 


914 

Gm. 

0.75 

0.9 

0.9 

0.9 

0.9 

0.9 

ascending 


Tertiary 

Intravenously 
Week  of  606 

treatment  Gm. 

1  0.5 

2  0.6 

3  0.6 

4  0.6 

5  0.6 

6  0.6 
9  Potassium    iodide    in 

doses  for  three  weeks 

14  Wassermann,  and  if  positive 

0.6  0.9 

10  0.6  0.9 

11  0.6  0.9 
Potassium     iodide     in     ascending 

doses  for  three  weeks. 
14  Wassermann,  and  if  negative,  ex- 
amination of  spinal  fluid,  and 
if  positive  further  series  of  606 
or  914,  untU  rendered  negative, 
or  that  impossibility  becomes 
apparent.  Thereafter  iodides 
and  mercun,'  by  inunctions, 
intramuscularly  or  by  mouth  for 
two  years.  Thereafter  mixed 
treatment  faU  and  spring 
throughout  life.  Blood  and 
spinal  fluid  should  be  examined 
at  yearly  inten,^als  and  positive 
findings  indicate  further  treat- 
ment bv  606  or  914. 


870 


GENITO-URINARY  SURGERY 


Intensive  Arsenical  Treatment  Associated  with  Mercury^ 


First  Course 

Intravenously 

Day  of 

914*     or 

606* 

Mercury 

treatment 

Gm. 

Gm. 

Cyanide  or 

Grey  Oil 

1 

0.45 

0.3 

2 

o.oit 

3 

0.01 

4 

0.01 

5 

0.06 

0.4 

6 

0.01 

7 

0.01 

8 

0.01 

9 

0.75 

0.5 

10 

0.01 

11 

0.01 

12 

0.01 

13 

0.01 

14 

0.9 

0.6 

15 

0.01 

16 

0.01 

17 

0.01 

18 

0.01 

19 

0.01 

20 

0.9 

0.6 

21 

0.01 

22 

0.01 

23 

0.01 

24 

0.01 

25 

0.01 

26 

0.01 

27 

0.9 

0.6 

28 

to 

33 

No  treatment 

34 

0.9 

0.6 

35 

o.u 

36 

to 

40 

No  treatment 

41 

0.9 

0.6 

42 

Rest  for  30  days. 

0.1 

Second  Course 

Intravenously 

Week  of 

914*     or 

606* 

treatment 

Gm. 

Gm. 

1 

0.45 

0.3 

o.it 

2 

0.6 

0.4 

0.1 

3 

0.75 

0.5 

0.1 

4 

0.9 

0.6 

0.1 

5 

0.9 

Rest  for  2  yi  months. 

0.6 

0.1 

Month  of 

treatment 
6 

Wassermann  (blood  and  spinal  fluid). 

1  Obviously  in  the  tertiary  stage  of  syphilis  the  iodides -are  also  employed. 
*  914  or  606,  used  as  a  convenience  and  does  not  refer  solely  to  the  original  German 
products. 

t  1  per  cent,  solution  in  ampoules  of  1  c.c. 
%  40  per  cent. 


THE  TREATMENT  OF  SYPHILIS  871 

Third  Course 

7  (Same  as  "Second,"  regardless  of  Wassermann) 

Rest  for  3  months. 

10  Wassermann  (blood  and  spinal  fluid). 

Fourth  C  our  St 

11  (Same  as  "Second") 
Rest  for  4  months. 

Year  of 
treatment 

1  WasseiTnann  (blood  and  spinal  fluid). 

If  negative — no  treatment. 
If  positive — repeat  "Second"  course. 
1^  Wassermann  (blood  and  spinal  fluid). 

2  Wassermann  (blood  and  spinal  fluid). 

If  negative — no  treatment. 
If  positive — repeat  "Second"  course. 

Administration  of  Salvarsan  and  Neosalvarsan 

Certain  precautions  are  needful  for  the  safe  administration  of  these  prepa- 
rations. The  water  in  which  they  are  to  be  dissolved  must  have  been  freshly 
distilled  in  a  Jena  glass  retort,  and  sterilized  immediately  thereafter.  The 
apparatus  used  must  be  rinsed  off  after  sterilization  with  distilled  water.  The 
drugs  must  be  dissolved  immediately  before  administration,  as  toxic  decomposi- 
tion occurs  if  they  be  permitted  to  stand.  The  intravenous  administration  only 
is  described  as  intramuscular  and  subcutaneous  injections  are  unjustifiably 
painful. 

Injections  are  usually  made  by  hydrostatic  pressure,  the  apparatus  consist- 
ing of  a  burette,  four  feet  of  rubber  tubing,  and  needle  (Fig.  11).  The  burette 
should  be  of  about  300  c.c.  capacity,  and  should  be  graduated  in  25-c.c.  divi- 
sions; a  glass  stopper  and  stopcock  are  convenient  additions;  permitting  laying 
the  burette  down  after  filling;  a  much  smaller  burette,  100  to  150  c.c,  is  large 
enough  for  the  administration  of  neosalvarsan  and  arsphenamine.  In  using  sal- 
varsan it  is  convenient  to  have  a  thermometer  inserted  at  this  point.  A  platino- 
iridium  or  gold  needle,  20-gauge,  is  most  serviceable.  A  slip-joint  connection  to 
the  tubing  is  a  convenience,  as  is  a  cock;  a  spring  clip  on  the  tubing  close  to  the 
needle  answers  every  purpose.  The  needle's  point  should  be  carefully  ground; 
whether  the  point  is  long  or  short  is  a  matter  of  individual  taste.  Other  neces- 
sary utensils  are  a  glass  mixing  cylinder  (50  c.c),  a  rod  thermometer,  and  a 
strip  of  rubber  dam,  12  by  3  inches;  and  if  salvarsan  is  to  be  used  a  small  glass 
funnel,  medicine  dropper,  and  15  per  cent,  solution  of  sodium  hydrate.  Freshly 
distilled  water  and  saline  solution  (0.9  per  cent.)  made  with  chemically  pure 
sodium  chloride  and  freshly  distilled  water  must  also  be  provided  (Fig.  422). 

Preparation  of  Salvarsan. — The  distilled  water  and  saline  solution  are 
warmed  to  a  point  somewhat  above  that  of  the  body  (110-  to  120'^  F.),  that 
they  may  be  delivered  to  the  needle  at  about  100  \  The  apparatus  is  rinsed 
with  one  of  the  solutions,  and  the  tubing  and  needle  are  filled  with  sahne 
solution.  The  salvarsan,  say  0.4  Gm.,  is  dissolved  in  30  or  40  c.c.  of  dis- 
tilled water  in  the  mixing  cylinder  by  vigorous  shaking,  neutralized  by  adding 
about  16  drops  of  the  hydrate  solution  (it  is  well  to  add  about  12  drops  first, 


872 


GENITO-URINARY  SURGERY 


THE  TREATMENT  OF  SYPHILIS 


873 


causing  a  marked  turbidity  of  the  solution,  and  then  to  continue  the  addition 
a  drop  at  a  time,  shaking  after  each  addition,  till  the  solution  becomes  once 
more  clear;  should  too  much  alkali  be  added,  the  mistake  may  be  corrected 


Fig.  -123. — Arrangement  of  patient  and  tables  for  administration  of  salvarsan  or  neosalvarsan. 
Note  the  easily  applied  and  released  rubber  dam  tourniquet  shown  in  the  corner  sketch,  also  the 
manner  of  fixing  the  skin  overlying  the  vein  with  the  thumb  or  index  finger  as  the  needle  is  intro- 
duced into  the  vein.  Observe  the  basin  ot  hot  or  cold  water  containing  section  of  tubing,  thereby 
readily  controlling  temperature  ot  injected  solution. 

with  a  few  drops  of  dilute  hydrochloric  acid).  This  solution  is  now  poured 
into  the  burette,  filtering  it  through  sterile  cotton,  and  the  bulk  brought  up 
to  200  c.c,  either  with  0.5  saline  solution,  as  generally  advised,  or  more  con- 


874  GENITO-URINARY  SURGERY 

veniently  with  a  mixture  of  water  and  0.9  per  cent,  saline  solution  (5  parts 
saline  solution  to  4  parts  water).  The  veins  of  the  patient's  arm  are  made 
prominent  by  fastening  about  it  a  strip  of  rubber  dam,  and  the  needle  passed 
through  the  skin  into  one  of  these  vessels  (Fig.  423).  Should  the  oper- 
ator be  in  doubt  as  to  whether  a  vein  has  been  entered,  the  needle  may  be 
disconnected,  when  a  flow  of  blood  will  announce  the  fact  if  the  needle  is  in 
the  proper  position.  The  tourniquet  is  then  removed  and  the  solution  al- 
lowed to  flow,  the  speed  being  so  regulated  by  the  elevation  of  the  burette 
that  about  eight  minutes  is  required  for  the  delivery  of  the  dose.  When  the 
surface  of  the  solution  is  at  the  neck  of  the  burette,  saline  solution  is  added 
to  wash  out  the  vein. 

There  are  very  few  cases  in  which  it  is  impossible  to  enter  a  vein  as  indi- 
cated above.  Occasionally,  however,  in  fat  individuals  with  small  veins  the 
needle  cannot  be  properly  inserted.  It  is  then  necessary  to  expose  a  vein 
under  infiltration  ansesthesia  and  insert  the  needle  by  the  sense  of  sight. 
A  vein  in  the  lower  extremity  should  be  selected  when  possible  to  avoid  con- 
spicuous scarring. 

Preparation  of  Neosalvarsan. — This  differs  from  that  of  salvarsan  in 
that  the  drug  is  given  in  cold  solution  (68°  to  72°  F.),  in  that  the  addition 
of  an  alkali  is  unnecessary,  in  that  a  smaller  amount  of  solution  is  used  (from 
10  to  150  c.c.  for  a  dose  of  0.9  Gm.),  and  in  that  shaking  is  not  permissible 
in  preparing  the  solution,  nor  any  delay  in  the  administration,  once  solution 
has  been  effected,  the  drug  being  much  more  easily  decomposed  than  the  older 
preparation.  It  has  been  our  custom,  in  order  to  avoid  delay,  to  partly  fill 
the  burette  with  saline  solution,  insert  the  needle,  and  prepare  the  solution 
by  very  gently  inverting  the  mixing  cylinder  while  the  saline  solution  was 
flowing  into  the  vein. 

Administration  by  Means  of  a  Syringe. — Neosalvarsan  may  be  admin- 
istered in  concentrated  solution  by  means  of  a  20-c.c,  glass  syringe.  The 
method  reduces  the  amount  of  fluid  injected,  and,  provided  the  injection  is 
made  slowly,  so  that  approximately  the  same  time  is  consumed  as  in  giving 
the  larger  bulk,  seems  to  be  attended  with  no  added  risk.  It  is  claimed  that 
reactions  are  less  likely  to  occur.  Assurance  may  be  had  that  the  needle  is 
in  the  vein  either  by  slightly  withdrawing  the  plunger  of  the  syringe,  or  by  dis- 
connecting the  needle.  Thompson  has  devised  an  ingenious  device  for  wash- 
ing the  vein  after  the  injection  by  connecting  two  syringes  to  the  needle  by 
means  of  a  three-way  cock;  it  has  the  disadvantage  of  added  bulk,  thereby 
making  the  guidance  of  the  needle  somewhat  more  difficult. 

ADMINISTRATION  OF  MERCURY 

This  drug  may  be  given  by  inunctions,  by  hypodermics,  by  mouth  ad- 
ministration, by  vaporization,  by  intravenous  injections,  named  in  the  order 
of  their  safety  and  usual  efficiency.  Excepting  the  intravenous  injections,  the 
amount  of  mercury  actually  absorbed  as  the  result  of  any  of  these  methods 
varies  greatly  from  time  to  time.  Hence,  while  during  a  long-continued  and 
uninterrupted  course  the  administered  dose  of  mercury  remains  the  same,  symp- 
toms of  uncontrolled  disease  may  appear  at  one  time,  those  of  drug  poisoning 


THE  TREATMENT  OF  SYPHILIS  875 

at  another.  The  intramuscular  injection  of  insoluble  salts  seems  almost  as 
uncertain  and  irregular  in  its  absorption  as  does  the  mouth  administration. 
Inunctions  and  intramuscular  injections  of  soluble  salts  are  safer  and  less 
subject  to  wide  variations.  In  whatever  form  it  be  given,  the  dosage  of  mer- 
cury is  the  largest  which  can  be  taken  and  absorbed  without  prejudice  to  the 
general  health. 

Salivation  is  never  to  be  produced,  and  the  drug  should  not  be  pushed  to 
the  development  of  even  early  symptoms  of  this  condition.  These  are:  (1) 
fetor  of  the  breath;  (2)  a  thickening  of  the  saliva  and  an  increase  in  its 
quantity;  (3)  boggy  swelling  of  the  gums  around  the  teeth,  and  a  tendency 
to  bleed  on  slight  irritation — so-called  sponginess  of  the  gums;  (4)  slight  ten- 
derness of  the  teeth  when  they  are  snapped  together,  and  a  feeling  as  though 
they  were  somewhat  longer  than  they  should  be;  (5)  a  metallic  taste  in  the 
mouth. 

It  is  only  when  the  mouth  and  teeth  are  clean  that  these  symptoms  are 
valuable  as  an  index  that  the  system  is  taking  all  the  mercury  it  can  absorb 
without  producing  marked  toxic  effects.  When  the  teeth  are  dirty,  caked  with 
tartar,  decayed,  and  clogged  with  masses  of  decomposing  organic  matter,  from 
carelessness  in  the  use  of  tooth-brush  and  tooth-washes,  or  from  neglect  in 
seeking  the  aid  of  the  dentist,  salivation  will  occur  from  doses  of  mercury 
far  below  those  necessary  to  saturate  the  system  to  the  limit  of  safety. 

If,  during  the  course  of  the  treatment,  the  mucous  membrane  of  the  mouth 
becomes  sore  or  the  gums  boggy,  cleansing  or  antiseptic  mouth-washes,  such 
as  saturated  solution  of  potassium  chlorate,  alternating  with  one  of  boric 
acid,  listerine,  and  water,  equal  parts  of  each,  or  a  weak  solution  of  boric 
and  tannic  acids  are  indicated ;  such  mouth-washes  have  a  prophylactic  influence 
against  the  development  of  salivation.  Applications  of  a  four  per  cent,  solu- 
tion of  eucaine  lactate  relieve  the  pain  incident  to  eating.  Sweating,  baths, 
laxatives,  and  diuretics  are  indicated  as  means  favoring  the  elimination  of 
mercury. 

The  weight  during  the  course  of  treatment  should  be  carefully  noted.  Sta- 
tionary or  increasing  weight  is  a  favorable  sign.  A  decrease  without  obvious 
cause,  when  this  decrease  is  rapid  and  progressive,  means  unchecked  disease  or 
toxic  dosage. 

Under  mercury  alone,  there  is  steady,  often  rapid,  subsidence  of  all  symp- 
toms. Lymphatic  adenopathy  diminishes,  and  often  disappears  completely, 
though  there  may  remain  traces  of  the  original  swelling;  the  eruption  fades, 
and  the  agonizing  pains  and  high  temperature  which  sometimes  usher  in  the 
secondaries  subside  promptly. 

The  end  to  be  obtained  is  repeated  full  treatments  over  a  long  period, 
with  intervals  of  rest.  The  dosage  should  be  just  short  of  the  production  of 
mercuric  intoxication,  or  injuriously  affecting  metabolism;  even  a  rr.Ild  ptyalism 
is  to  be  scrupulously  avoided,  since  it  increases  tissue  vulnerability.  When 
mercury  is  being  properly  administered  the  patient,  in  addition  to  being  free 
of  symptoms  characteristic  of  syphilis,  should  gain  rather  than  lose  in  weight, 
and  should  have  a  special  sense  of  well-being. 


876  GEXITO-URIXARY  SURGERY 


Mouth  Administration 

There  are  some  patients  to  whom  mercuric  treatment  cannot  be  given  by 
other  means,  and  many  in  whom  this  method  is  as  efficient  as  any  other, 
and  less  disturbing.  The  latter  are  represented  by  those  who  can  take  a  dose 
sufficient  to  control  symptoms  without  disturbing  digestion  or  causing  colic. 
The  irregularities  of  absorption  are  perhaps  greater  than  those  incident  to 
other  methods,  hence  if  mercur\^  be  routinely  given  by  the  mouth  the  method 
should  be  varied  occasionally  by  dermal  or  subdermal  methods. 

As  a  routine  practice,  it  is  well  to  adhere  to  the  administration  of  the  protio- 
dide,  the  bichloride,  or  gra\^  powder,  preference  being  given  to  the  first  drug, 
the  others  being  emplo3'ed  only  when  the  protiodide  produces  undue  irritation 
without  favorably  influencing  the  course  of  the  disease. 

^^^len  few  remedies  are  tried,  the  surgeon  becomes  more  familiar  with  their 
strength  and  special  properties,  and  hence  is  more  likely  to  employ  them  skil- 
fully than  if  he  used  many  salts  of  mercun,',  the  special  reactions  of  which 
are  unknown  to  him. 

If  the  protiodide  is  selected,  compressed  tablets  are  ordered,  each  containing 
one-third  to   one-sixth  of  a  grain. 

The  patient  is  directed  to  take  three  pills  daily  for  the  first  three  days, 
four  for  the  second  three,  five  for  the  third,  and  so  increase  the  dose  by  one 
pill  every  third  day,  the  salivary  secretion,  the  urine,  the  gastro-intestinal  condi- 
tion, the  body  weight,  and  the  mental  attitude  being  carefully  observed,  usually 
at  intervals  of  three  days. 

The  patient's  reaction  to  the  drug  is  most  certainly  shown  by  metallic 
taste,  fetor  of  the  breath,  and  loss  of  weight  and  appetite.  Mild  colicky 
diarrhoea  is  frequently  considered  a  sign  that  the  full  dose  of  mercury  has  been 
reached:  this  symptom,  however,  shows  only  the  reaction  of  the  intestinal 
mucous  membrane  to  the  particular  preparation  of  mercury  that  is  being  used. 
Colic  and  diarrhoea  may  occur  long  before  enough  mercury  has  been  given  to 
influence  the  course  of  early  s^^hilis.  These  symptoms  indicate  defective  ab- 
sorption of  the  drug,  and  show  that  only  a  fractional  part  of  the  daily  dose 
administered  is  reaching  the  general  circulation;  hence  the  adoption  of  colicky 
diarrhoea  as  a  gauge  of  constitutional  susceptibility  may  lead  to  error,  and 
may  result  in  insufficient  treatment  and  its  disastrous  consequences. 

If  during  early  treatment  colic  and  diarrhoea  develop  before  the  manifesta- 
tions of  syphilis  are  markedly  influenced  for  the  better,  the  protiodide  should 
be  withdrawn,  and  in  its  place  pills  of  mercury  and  chalk  should  be  admin- 
istered: 

Tab.     Hydrarg.   cum   creta.,   gr.    i. 
No.  50. 

These  pills  are  administered  exactly  as  are  those  of  protiodide  of  mercury, 
beginning  with  three  pills  a  day  and  gradually  increasing  the  dose  till  it  is 
evident  that  the  lesions  are  rapidly  disappearing.  A  grain  of  mercury  and 
chalk  produces  a  somewhat  less  powerful  effect  than  the  third  of  a  grain  of 
protiodide. 


THE  TREATMENT  OF  SYPHILIS  877 

If  the  gastro-intestinal  irritation  persists,  unaccompanied  by  symptoms  of 
ptyalism,  bichloride  of  mercury  may  be  tried. 

R     Hydrarg.   chlorid.   corrosiv.,   gr.   iv; 
Confect.  ros.,  q.s. 

M.    et  ft.  pil.  no.  Ix. 

^     Hydrarg.  chlorid.  corrosiv.,  gr.  ii ; 
Mucilag.  acacise, 
Aquse,  aa  Biv. 

M.  S.     Teaspoonful  freely  diluted,  as  directed. 

If  the  change  to  these  prescriptions  is  not  successful  in  subduing  the  symp- 
toms of  gastro-intestinal  irritation,  another  method  of  introducing  mercury  is 
indicated. 

When  the  patient  is  so  situated  that  such  change  is  impossible,  opium  in 
sufficient  quantity  to  control  the  diarrhoea  may  be  combined  with  one  or  other 
of  the  formulae  already  given  until  the  full  dose  is  determined  by  rapid  dis- 
appearance of  symptoms.  It  should  then  be  withdrawn,  since  it  tends  to 
constipate,  to  reduce  appetite,  and  generally  to  influence  the  system  unfavor- 
ably. 

The  best  method  of  administering  opium,  when  this  is  required  to  deter- 
mine the  full  dose,  is  in  the  form  of  paregoric.  With  each  mercurial  pill  the 
patient  is  directed  to  take  the  smallest  number  of  drops  which  will  prevent 
griping  diarrhoea;  thus  the  minimum  efficient  quantity  can  be  found  and 
can  be  administered  in  a  form  towards  which  the  stomach  is  fairly  tolerant. 

Zittmann's  decoction  is  an  elaborate  preparation,  containing  sarsaparilla, 
calomel,  cinnabar,  alum,  anise-  and  fennel-seeds,  senna  leaves,  and  liquorice 
root.  The  special  virtue  of  this  decoction  is  incident  to  the  elimination  pro- 
duced by  diaphoresis  and  purgation.  For  details  and  technique  of  its  ad- 
ministration, see  p.  886. 

Blue  mass  is  a  favorite  with  many,  syphilographers.  The  best  combinations 
of  this  drug  are  as  follows  (Bumstead): 

IJ     Mass.  hydrarg.,    Sii; 

Ferri  sulph.   exsiccat.,    9i; 
Ext.   opii,   gr.   v. 

M.    et  in  pil.  no.  xx  div. 

S. — One  pill  from  two  to  four  times  daily. 

^     Mass.  hydrarg.,    3i; 

Hydrarg.    chlorid.   mit.,    9ss; 
Hydrarg.  cum  creata,   3ii; 
Ext.  opii,  gr.  v. 

M.    et  in  pil.  no.  xx  div. 

S. — From  tvifo  to  four  pills  daily. 

The  last  prescription  is  ordered  when  a  rapid  constitutional  effect  is  desired. 

The  tolerance  to  mercury  is  greatly  increased  by  hot  baths  taken  daily 

during  the  course  of  treatment,  preferably  hot-air  baths;   when  these  cannot 


878  GENITO-URINARY  SURGERY 

be  obtained,  hot-water  baths.    Against  hot  baths  some  patients  exhibit  a  pro- 
hibitive idiosyncrasy. 

Inunctions 

In  prescribing  mercury,  the  patient  is  ordered  freshly  made  Unguent. 
Hydrarg.  (50  per  cent.  Hydrarg.)  put  up  in  cachets  or  waxed  paper.  The 
average  dose  for  men  is  5i  for  six  days  in  succession,  with  an  interval  of  five 
days,  or  double  or  triple  this  dose  is  at  times  needful,  the  quantity  administered 
being  increased  till  the  specific  lesion  for  the  cure  of  which  it  is  given  shows 
signs  of  involution.  For  women  the  average  beginning  dose  is  forty  grains. 
When  the  skin  is  hypersensitive  an  equal  quantity  of  petrolatum  may  be 
added.  Mercurettes  about  two-thirds  as  strong,  made  with  cocoa  butter  as 
a  base,  are  equally  efficient  and  more  convenient.  Or  mercurial  ointment  cap- 
sules may  be  ordered  (mercury  33  per  cent.,  lanolin  45  per  cent.,  olive  oil  6.6 
per  cent.,  white  petrolatum  15  per  cent.),  each  containing  5ss-oi. 

The  patient  should  provide  himself  with  an  undershirt  of  a  thickness 
suitable  to  the  time  of  year  and  of  such  quality  or  condition  that  no  great 
loss  will  be  suffered  from  its  being  permanently  stained.  This  should  be  worn 
every  night  of  treatment  without  being  washed,  the  ordinary  night  clothes  being 
put  on  over  it.    , 

Whenever  practicable,  he  should  do  his  own  rubbing,  beginning  after  his 
first  hot  bath  (air,  vapor,  or  water).  He  should,  after  his  bath  and  immedi- 
ately before  retiring,  occupy  fully  ten  minutes  in  rubbing  in  the  amount  of 
ointment  prescribed  for  one  treatment. 

Since  this  ointment  irritates  the  skin  if  its  application  is  too  frequently 
repeated  in  one  place,  different  surfaces  are  selected  on  successive  nights. 
These  surfaces  should  be  comparatively  hairless  and  fairly  accessible.  The 
regions  of  preference  are  the  antero-internal  surfaces  of  the  arms  and  fore- 
arms, the  sides  of  the  thorax,  the  flanks,  and  the  antero-lateral  surfaces  of  the 
abdomen.  WTien  the  nurse  does  the  nibbing,  the  whole  back  may  be  in- 
cluded. By  passing  from  one  to  the  other  of  these  regions  in  a  definite  order 
no  one  of  them  need  be  used  oftener  than  once  a  week,  thus  giving  plenty  of 
time  for  the  subsidence  of  any  slight  irritation  which  the  inunction  may  occa- 
sion. After  the  inunction  the  patient  puts  on  his  undershirt  and  night  clothes 
and  goes  to  bed.  The  following  morning  he  bathes  and  dresses  as  usual,  remov- 
ing the  stained  undershirt. 

If  there  is  marked  skin  irritation  in  any  particular  locality,  this  whole 
region  is  carefully  washed  with  soap  and  hot  water  and  dusted  with  a  mixture 
of  starch  and  bismuth,  or  stearate  of  zinc.  Inunctions  are  taken  before  going 
to  bed  simply  as  a  matter  of  convenience;  they  may  be  given  at  any  time 
during  the  twenty-four  hours. 

The  patient  resumes  at  night  after  his  next  rubbing  the  undergarments 
already  soiled  by  the  ointment.  The  continued  surface  application  of  that 
portion  of  the  ointment  remaining  after  all  has  been  rubbed  in  that  the  skin 
will  receive  seems  to  be  an  important  feature  in  bringing  about  full  absorption. 

It  is  undoubtedly  true  that  some  persons  exhibit  an  idiosyncrasy  against 
inunctions,  eczematous  eruptions  appearing  over  the  entire  body,  and  in  the 
blonde  and  thin-skinned  the  local  irritation  is  sometimes  so  great  that  this 
method  of  treatment  is  not  applicable. 


THE  TREATMENT  OF  SYPHILIS  879 

In  place  of  ointments,  mercurial  soaps  have  been  advised.  These  are, 
however,  more  uncertain  in  their  effects  and  less  accurate  in  their  composi- 
tion than  ointments,  and,  although  cleaner,  require  more  time  in  their  applica- 
tion. Schuster  employs  a  soap  commended  by  Charcot,  which  is  made  of  equal 
parts  of  mercury,  mutton  suet,  and  potash  soap.  These  ingredients  are  gently 
heated,  and  to  them  is  added  enough  potassium  hydrate  to  produce  saponi- 
fication. This  mixture  is  rubbed  into  the  skin  for  from  fifteen  to  twenty 
minutes  exactly  as  is  mercurial  ointment. 

Mercury  plasters  have  also  been  proposed,  but  have  as  yet  received  scanty 
recognition.  Chassaignac  employed  the  emplastrum  de  Vigo  cum  mercurio, 
which  contains  metallic  mercury  triturated  with  styrax  and  turpentine  and 
added  to  ordinary  lead  plaster.  Quinquaud  obtained  excellent  results  from 
a  calomel  plaster  made  by  suspending  1000  parts  of  calomel  in  300  parts  of 
castor  oil  and  adding  3000  parts  of  melted  diachylon  plaster.  This  mixture 
is  spread  on  linen,  is  applied  to  the  skin,  and  is  kept  on  for  eight  days.  The 
plaster  should  be  about  sixteen  inches  square,  and  should  contain  about  three 
drachms  of  calomel. 

Intramuscular   Injections 

The  specific  claims  made  for  this  treatment  are  as  follows:  (1)  A  precise 
dosage  is  obtainable;  (2)  it  saves  time  and  labor  on  the  part  of  both  physi- 
cian and  patient,  visits  being  rendered  infrequent;  (3)  it  necessitates  little 
change  of  diet  or  of  habits  of  life;  (4)  the  patient's  skin  and  digestive  organs 
remain  unaffected,  except  in  rare  instances;  stomatitis  is  exceptional;  (5)  the 
disease  is  readily  concealed;  (6)  there  is  lessened  expense;  (7)  permanent  cure 
is  accomplished  in  a  short  time  and  with  a  minimal  amount  of  mercury;  (8) 
a  powerful  influence  is  exerted  readily  and  surely  in  the  presence  of  grave 
and  threatening  visceral  troubles;  (9)  the  time  required  for  a  therapeutic  diag- 
nosis is  shortened  in  doubtful  cases. 

On  the  other  hand,  evidence  is  adduced  showing  that  the  method  does 
not  assure  accurate  dosage  (through  irregular  absorption),  does  not  cure  per- 
manently or  quickly,  does  at  times,  but  not  always,  exert  a  prompter  influ- 
ence than  can  be  obtained  by  other  methods. 

The  disadvantages  of  the  method  are:  (1)  It  is  often  extremely  painful 
and  is  strongly  objected  to  by  many  patients;  (2)  it  is  sometimes  followed 
by  dangerous  and  even  rapidly  fatal  toxic  symptoms;  (3)  it  may  have  local 
sequelae,  such  as  erythema,  cellulitis,  abscess,  and  sloughing;  (4)  it  is  a  treat- 
ment which  cannot  be  carried  out  by  the  patient  himself,  but  usually  requires 
frequent  visitation  to  the  surgeon. 

The  drugs  employed  in  the  hypodermic  method  of  treatment  are  either 
soluble  or  insoluble.  In  each  class  there  are  many  preparations.  Those  most 
widely  used  are  corrosive  sublimate,  the  cyanide,  the  benzoate,  the  sali- 
cylate, and  metallic  mercury.  Even  with  careful  antiseptic  precautions,  ab- 
scesses occasionally  develop. 

The  pain  incident  to  these  injections  varies  greatly;  occasionally  it  lasts 
for  hours  or  even  days,  and  is  usually  more  severe  with  the  insoluble  salts 
of  mercury  Tenderness  persists  for  some  time,  and  may  be  so  great  as  to 
occasion  almost  complete  disability. 


880  GENITO-URINARY  SURGERY 

When  a  soluble  preparation — and  the  best  are  corrosive  sublimate,  the  ben- 
zoate,  and  the  cyanide — is  employed,  the  dose  of  the  first  two  is  from  one- 
twelfth  to  one-third  of  a  grain,  of  the  last,  one-seventh  of  a  grain  (0.01  Gm.). 
A  hypodermic  containing  this  quantity  of  the  drug  may  be  administered  daily 
for  from  six  to  eighteen  days;  a  period  of  rest  half  the  length  of  the  course 
is  then  given.  When  on  account  of  its  situation  an  outbreak  of  syphilis  be- 
comes immediately  dangerous,  as  in  the  brain,  and  prompt  action  is  impera- 
tive, larger  doses  may  be  injected. 

These  injections  are  indicated  when  syphilitic  lesions  are  developing  in 
spite  of  other  methods  of  treatment  or  where  there  exists  an  idiosyncrasy  against 
arsphenamine  (salvarsan),  or  as  an  associated  or  supplemental  treatment  to 
arsenic,  or  when  the  intravenous  arsphenamine  or  modern  method  of  treat- 
ment is  inadvisable  on  account  of  nephritis  or  other  organic  contra-indication, 
or  when  syphilomata  are  particularly  obstinate.  The  favorite  formula  is  the 
following: 

R      Hydrarg.  chlor.  corros.,  gr.  4?{o 
Sodii  chlor.,  gr.  iiiss; 
Aquae  destil.,  fgi. 

S. — One  per  cent,  solution  of  corrosive  mercuric  chloride.     Ten  to  thirty  minims 
intramuscularly. 

The  benzoate  in  2  per  cent,  solution  with  2.5  per  cent,  sodium  chloride  is 
given  in  one-sixth  to  one-third-grain  doses, 

B      Hydrarg.  benzoat,  gr.  x; 
Sodii  chloridi,  gr.  xiiss; 
Aquae  destil.,  f5i. 

The  cyanide  of  mercury  is  conveniently  employed  in  one  per  cent,  solution 
put  up  in  sterile  ampules.  The  dose  of  this  preparation  is  one  cubic  centi- 
metre  (0.01  Gm.). 

Of  the  insoluble  preparations  administered  hypodermically,  metallic  mer- 
cury and  calomel  are  most  efficient. 

They  are  given  in  doses  of  ^  to  2  grains  and  %  to  ^  grain  respectively 
at  weekly  intervals.     Lambkin's  formulae  for  these  preparations  are: 

R      Hydrargyrum  purum,  10  Gm. 
"Creo-camph."  *  20  c.c. 
Palmitin  basis,  to  100  c.c. 

Sig.   10  minims  contains  1  gr.  of  metallic  mercury. 

R     Calomel,  5  Gm. 

"Creo-camph,"  *  20  c.c. 
Palmitin  basis,  to  100  c.c. 

Sig.  10  minims  contains  calomel  j4  grain. 

*  Equal  parts  of  absolute  creosote  and  camphoric  acid. 


THE  TREATAIENT  OF  SYPHILIS  881 

For  the  injection  of  mercury  and  its  salts  an  all-glass  syringe  and  platinum 
needle,  2  inches  in  length,  about  20  gauge,  should  be  used.  When  insoluble 
preparations  are  used,  needle  and  syringe  shoifid  be  sterilized  by  heat  in  olive 
oil;  the  syringe  is  filled  by  removing  the  plunger  and  placing  the  mass  in  the 
barrel  with  the  flat  end  of  a  probe. 

The  buttock,  above  and  behind  the  trochanter,  is  the  region  of  preference 
for  the  injection  (Fig.  424);  sometimes  the  muscles  beside  the  spine  in  the 
thoracic  region  are  used.    The  needle  should  be  driven  vertically  into  the  tissues 


Fig.  424. — Intramuscular  injection  of  mercury.     The  cross  (X)  is  over 
the  trochanter,  the  line  over  the  iliac  crest. 

down  to  the  guard  by  one  quick  thrust.  It  should  be  obser\^ed  for  a  moment  to 
see  if  any  blood  flows  from  it,  and,  if  not,  the  syringe  should  be  attached  and 
the  injection  driven  in  slowly.    Successive  injections  are  made  on  opposite  sides. 

The  rate  of  absorption  varies  greatly,  mercuric  poisoning  expressed  in  the 
form  of  stomatitis  or  gastro-enteritis  may  occur  weeks  after  a  series  of  injections; 
some  accidents  from  emboli  incident  to  an  accidental  venous  injection  are 
reported. 

Thus  administered,  mercury  usually  exercises  a  prompt  and  powerful 
effect  upon  the  lesions  of  syphilis,  particularlv  those  of  the  secondary  stage  of 
56 


882  GENITO-URINARY  SURGERY 

the  disease  and  certain  affections  of  the  eye  and  connective  tissues.  This  effect 
is  prolonged  and  continued,  the  drug  presumably  remaining  at  the  point  of 
injection  as  a  magazine  from  which  steady  absorption  goes  on.  Clinically  the 
results  are  good  and  the  accidents  few. 

In  the  tertiary  stage,  in  conjunction  with  the  iodides,  this  method  of  treat- 
ment is  valuable  when  the  integrity  of  vital  organs  is  threatened  and  when 
the  daily  injection  of  soluble  salts  is  not  practicable. 

Metallic  mercury  is  usually  preferred  to  calomel  when  no  special  urgency 
exists. 

Value  cf  the  Intramuscular  Method. — This,  the  fashion  of  the  day,  owes 
its  vogue  to  its  convenience.  Moreover,  it  is  clinically  efficient,  more  so,  as  a 
rule,  than  mouth  administration,  less  so  than  inunctions.  But  all  three  methods 
vary  in  individual  cases,  and  from  time  to  time  in  the  same  individual;  hence 
none  can  claim  accuracy  of  dosage. 

Indications. — Mercury  should  be  administered  intramuscularly  in  those 
cases  in  which  other  methods  of  treatment  have  failed  or  cannot  be  applied 
because  of  especially  sensitive  conditions  of  either  the  gastro-intestinal  mucous 
membrane  or  the  skin,  or  because  of  an  environment  making  it  needful  that 
the  treatment  be  given  by  the  doctor,  and  where  prompt  therapeutic  effect  is 
imperative. 

Choice  of  Preparations. — The  soluble  salts  are  to  be  preferred  to  the  insol- 
uble in  the  large  majority  of  cases,  because  of  more  rapid  utilization  and  the 
lessened  danger  of  local  accumulation,  with  the  sudden  absorption  of  a  toxic 
dose.  The  stability  and  solubility  of  the  bichloride  commend  it  as  the  salt  of 
choice  when  soluble  salts  are  employed. 

Insoluble  salts  should  be  reserved  for  cases  healthy  except  for  syphiiitics 
who  cannot  be  depended  upon  to  take  intelligently  inunctions  or  internal  medi- 
cation according  to  directions.  Sailors,  the  passing  type  of  drummers,  and 
"  rounders  "  still  not  "  burnt  out  "  well  represent  this  type.  Of  the  insoluble 
preparations,  metallic  mercury  and  calomel  are  to  be  preferred,  the  former  for 
routine  use,  the  latter  when  there  are  urgent  symptoms,  but  daily  injections 
of  a  soluble  preparation  are  impossible. 

Centra-indication. — In  cases  of  crippled  kidneys,  diabetes,  profound  anaemia, 
marked  atheroma,  great  debility,  or  any  profound  systemic  dyscrasia,  whether 
or  not  depending  directly  upon  syphilis,  the  hypodermic  method  of  treatment 
is  dangerous. 

Vaporization 

This  method  of  introducing  mercury  into  the  system  has  practically  been 
abandoned  as  a  routine  practice,  since  it  is  more  troublesome  than  other  methods, 
is  more  difficult  to  apply  privately,  and  is  in  the  majority  of  cases  not  attended 
by  better  results.  The  drug  commonly  employed  is  calomel;  the  average  dose 
is  twenty  grains. 

The  apparatus  consists  of  an  alcohol  lamp  placed  beneath  a  metallic  saucer, 
which  is  supported  on  a  tripod.  This  apparatus  is  placed  beneath  a  cane-bot- 
tomed chair,  upon  which  the  patient  is  seated  naked  and  with  a  blanket  pinned 
tightly  around  his  neck  and  dropping  to  the  l!oor,  enclosing  the  body  and  the 
chair  in  a  tent.    Twenty  grains  of  calomel  are  placed  in  the  metallic  dish,  the 


THE  TREATMENT  OF  SYPHILIS  883 

alcohol  lamp  is  lighted,  and  the  blanket  is  draped  around  the  patient.  The 
lamp  is  extinguished  at  the  end  of  twenty  minutes,  and  the  patient  is  allowed  to 
sit  for  twenty  minutes  longer  in  the  calomel  vapor;  he  then  wraps  himself  in 
the  same  blanket  that  he  has  used  during  the  vaporization,  and  retires  to  bed 
for  a  couple  of  hours,  or  for  the  night  if  the  vaporizations  are  administered 
before  going  to  bed. 

There  should  be  some  one  present,  or  at  least  within  call,  during  these 
vaporizations,  since  the  heat  and  the  concentrated  attention  of  the  patient 
sometimes  produce  syncope. 

This  treatment  is  indicated  when  other  methods  have  failed,  and  particu- 
larly in  cases  of  widely  diffused,  small,  hard,  papular  syphilides,  or  when 
obstinate  or  precocious  ulcers  are  present. 

Local  vaporization  is  sometimes  efficacious  in  the  treatment  of  obstinate 
plantar  or  palmar  syphilides.  The  foot  or  the  hand  may  be  kept  in  a  box 
filled  with  the  vapor  of  mercury  for  one  or  two  hours  daily. 

Mercuric  Baths,   Thermal   Springs-,   and   Heat 

Mercuric  baths  administered  for  the  purpose  of  causing  absorption  of  the 
drug  have  been  little  employed,  since  other  methods  are  more  exact  and  easier 
of  application.  The  value  of  such  baths,  however,  in  combating  by  direct  action 
certain  widespread  skin-lesions,  and  particularly  in  exerting  an  antiseptic  effect 
upon  pustular  and  ulcerating  eruptions,  thus  minimizing  or  altogether  preventing 
the  effects  of  pyogenic  infection,  is  undoubted. 

In  papular  and  pustular  syphilides,  papular  and  ulcerating  gummata,  and 
moist  papules,  the  baths  are  serviceable,  particularly  in  cachectic  patients  who 
do  not  well  support  vigorous  treatment  by  the  mouth.  Tubercular  and  gum- 
matous skin  affections  are  also  beneficially  acted  upon  by  this  method  of 
treatment. 

When  the  whole  body  is  not  involved  in  the  lesions  the  partial  bath  may  be 
employed.  Lesions  about  the  genitalia  and  the  rectum  may  be  benefited  by  a 
sitz-bath,  or  in  case  of  plantar  or  palmar  psoriasis  or  syphilitic  onychia  the  hands 
or  the  feet  alone  may  be  submerged. 

The  strength  of  the  bath  should  be  about  1  to  20,000,  the  temperature  one 
comfortable  to  the  patient,  the  duration  at  least  two  hours. 

Thermal  Springs. — In  this  country,  the  Hot  Springs  of  Arkansas,  abroad, 
the  Baths  of  Aix,  are  widely  known  and  extensively  patronized  for  the  supposed 
specific  effects  of  the  water  upon  syphilis.  The  general  opinion  of  the  pro- 
fession is,  however,  that  the  waters  of  these  springs  have  no  special  remedial 
value,  and  that  hot  salt  baths  at  the  sea-shore,  or  hot  tub-baths  at  a  wholesome 
mountain  resort,  would  be  equally  useful  to  those  who  derive  the  most  benefit 
from  the  springs. 

The  patients  who  should  be  sent  to  the  springs  are — 

1.  Those  whose  mode  of  life  is  unhygienic  and  who  cannot  be  controlled 
while  under  home  or  other  customary  influence.  This  includes  patients  addicted 
to  excesses,  especially  in  the  direction  of  alcohol  and  tobacco,  and  those  whose 
devotion  to  work  is  so  close  and  constant  as  to  interfere  with  their  general  health. 
2.  Those  whose  symptoms  resist  full  doses  of  the  specific  drugs  or  who  are 


884  GENITO-URINARY  SURGERY 

unable  to  take  large  doses  without  a  break-down  of  the  digestive  apparatus  or 
the  production  of  mercurial  or  iodic  intoxication.  Under  such  circumstances, 
should  there  be  involvement  of  the  viscera  or  of  the  brain  or  spinal  cord,  the 
Hot  Springs  treatment  is  particularly  indicated.  3.  Those  who  with  syphilis 
have  intense  syphilophobia,  and  who  require  the  mental  impression  and  in 
addition  the  tonic  influence  of  change  of  scene  and  climate.  4.  Those  with 
defective  elimination  or  with  marked  idiosyncrasy  as  regards  either  mercury 
or  the  iodides. 

The  course  of  treatment  adopted  at  the  springs  has  for  its  active  principle 
the  administration  of  the  specific  drugs;  practically  no  dependence  is  placed 
upon  the  waters  as  curative  agents.  Aided  by  the  increased  elimination  and 
greater  tissue-activity  which  these  waters  encourage,  larger  quantities  of  mercury 
and  iodide  are  administered  than  would  be  tolerated  under  ordinary  circum- 
stances. The  mercury  is  usually  given  in  the  form  of  inunctions,  and,  if  the 
symptoms  call  for  it,  large  doses  of  the  iodides  are  administered. 

Patients  who  come  to  the  springs  after  a  long  mercurial  course  at  home 
with  the  idea  of  "  boiling  out "  the  mercury,  of  which  they  suppose  their 
system  to  be  full,  sometimes  develop  ptyalism  after  a  number  of  baths,  thus 
showing  that  the  waters  have  an  influence  in  increasing  capillary  circulation 
favoring  tissue-change,  and  causing  greater  activity  in  the  elimination  of  matter 
foreign  to  the  tissues.  Persons  coming  from  malarial  regions,  though  they 
have  had  no  previous  outbreak  of  malaria,  after  one  or  two  weeks  sometimes 
develop  typical  fever.  Gouty  subjects  are  liable  to  suffer  from  outbreaks  of 
this  trouble,  and  malignant  tumors  are  prone  to  grow  with  increased  activity. 
It  seems  reasonable  to  suppose  that  the  increased  tissue-change  brought  about 
by  the  hot  baths  will  be  useful  in  hastening  the  sequestration  or  destruction 
of  the  syphilitic  infection.  Moreover,  the  general  health  is  often  benefited 
by  change  of  air  and  scenery. 

Whatever  be  the  action  of  the  Hot  Springs,  it  is  true  that  under  their  influ- 
ence patients  in  a  profound  state  of  cachexia  who  have  been  unsuccessfully 
treated  by  competent  physicians  sometimes  improve  rapidly,  and  that  some 
cases  of  late  syphilis  are  more  quickly  cured  at  the  springs  than  at  home. 

Sulphur  baths  do  not  differ  in  reaction  from  those  of  ordinary  springs. 
Sodium  chloride  and  iodine  brine  baths  seem,  however,  to  increase  oxidation. 

The  danger  incident  to  bath  treatment  lies  in  over-confidence  in  the  healing 
virtues  of  the  springs,  thus  leading  patients  to  stop  all  treatment  after  the 
symptoms  have  disappeared,  with  the  idea  that  they  are  permanently  cured, 
and  substituting  short  and  heroic  treatment  for  the  prolonged  course  which 
they  require. 

Hot  Baths, — The  value  of  hot  baths  as  adjuvants  in  the  specific  treatment 
of  syphilis  is  beyond  dispute,  and  it  is  well  to  order  as  a  routine  practice  during 
the  time  that  mercury  is  administered  the  daily  administration  of  a  hot-air  or 
hot-water  bath,  continued  for  ten  to  twenty  minutes,  and  taken  either  at  night 
on  retiring  or  in  the  morning,  according  to  the  convenience  or  inclination  of  the 
patient. 

The  elimination  of  mercury  is  facilitated,  larger  quantities  are  tolerated, 
and  in  certain  cases  where  without  the  baths  doses  of  the  specific   far  too 


THE  TREATMENT  OF  SYPHILIS  885 

small  to  influence  materially  the  lesions  of  syphilis  produce  beginning  ptyalism, 
efficient  doses  can  be  given  without  untoward  symptoms. 

These  baths,  if  of  hot  water,  should  be  from  100"  to  104°  F.;  if  of  air,  from 
150^  to  180°  F.  In  ordering  them  the  question  of  idiosyncrasy  should  be 
fully  considered;  during  their  administration  the  patient  should  have  an  attend- 
ant at  hand,  in  case  syncope  be  produced. 

Heat  thus  applied  to  the  general  surface  increases  the  elimination  of  the 
mercury,  even  in  the  urine,  probably  because  of  the  more  active  tissue-changes 
excited  by  the  bath.  Thus,  when  hydrargyrism  develops,  the  application  of  the 
hot  baths  affords  one  of  the  most  active  and  efficient  means  of  relieving  symp- 
toms. The  hot-air  baths  seem  to  be  particularly  serviceable,  since  they  occasion 
free  diaphoresis  and  elimination  of  the  mercury  through  the  sweat-glands;  in 
consequence  of  the  thirst  they  excite,  bland  liquids  are  ingested  in  large  quan- 
tities, and  these  being  taken  up  into  the  circulation  tend  to  increase  metab- 
olism. A  box  heated  with  electric-light  bulbs  affords  the  best  means  of  giving 
the  hot-air  bath.  In  the  absence  of  electricity  a  flame  in  a  box  answers 
fairly  well. 

The  local  application  of  heat  often  markedly  hastens  the  disappearance  of 
syphilitic  lesions  when  judicious  treatment  is  employed  at  the  same  time.  Heat 
may  be  applied  locally  in  the  form  of  baths,  lasting  for  one  or  two  hours,  or, 
when  these  are  not  practicable,  in  the  form  of  hot  compresses  wrung  out  of 
hot  corrosive  chloride  solution  and  covered  with  a  hot-water  bag. 

Indurations,  gummata,  periosteal  nodes,  and  obstinate  ulcerating  syphilides 
are  particularly  amenable  to  the  combined  action  of  local  heat  and  general 
specific  treatment. 

Intravenous  Injection  of  Mercury  w 

Intravenous  injections  of  corrosive  sublimate  solution  theoretically  insure 

more  exact  dosage  and  a  more  rapid  and  powerful  effect  upon  syphilitic  lesions 

than  when  larger  doses  of  mercury  are  given  in  other  ways. 

Nixon's  method,   modified  by  Thompson,   is  as  follows:     A  20-c.c.  glass 

syringe  half  full  of  normal  salt  solution  has  added  to  it  five  to  fifteen  minims 

of  a  2  per  cent,  solution  of  bichloride.    After  thoroughly  mixing,  the  needle  is 

introduced  into  a  vein,  the  barrel  of  the  syringe  filled  by  drawing  out  10  c.c. 

of  blood,  and,  finally,  this  mixture  of  mercuric  solution  and  blood  is  driven  into 

the  vein.    This  mixture  does  not  cause  thrombosis. 

The  method  is  useful  in  cases  demanding  intensive  mercurial  treatment  in 

whom  intramuscular  injections  of  soluble  preparations  produce  an  unjustifiable 

amount  of  pain.     The  pain  of  intravenous  injections  skilfully  administered  with 

a  fine,  sharp  needle  is  negligible. 

The  Elimination  of  Mercury 
The  elimination  of  mercury  begins  very  shortly  after  the  administration  of 
the  drug:  thus,  examination  of  the  urine  usually  shows  its  presence  two  hours 
after  intramuscular  injection.  The  kidneys,  the  intestinal  mucous  membrane, 
and  the  salivary  glands  are  chiefly  active  in  eliminating  mercury  from  the 
system. 


886  GEXITO-URIXARY  SURGERY 

THE  TOXIC  EFFECTS  OF  MERCURY 

Hydrargyrism. — Hydrargyrism  may  be  either  acute  or  chronic.  The  symp- 
toms of  either  of  these  conditions  may  be  occasioned  by  the  introduction  of 
mercury  into  the  system,  whether  it  be  by  way  of  the  aHmentary  tract,  through 
the  skin,  as  when  the  drug  is  administered  by  inunction,  vaporization,  or  baths, 
or  through  the  muscles  and  subcutaneous  tissue,  as  when  preparations  of  mer- 
cury' are  administered  hypodermically.  It  should  be  borne  in  mind  that  lesions 
of  the  kidney  particularly  predispose  to  the  development  of  hydrargyrism. 

Acute  Hydrargyrism. — The  mild  form  of  acute  hydrargyrism  is  that 
alread}'  described.  The  S3'mptoms  are  a  slight  ropiness  or  stringiness  of  the 
saliva,  with  increase  in  its  quantit}'.  During  the  night  there  is  some  flow  from 
the  corners  of  the  mouth.  The  gums  are  slightly  congested,  and  bleed  readily 
when  touched.  This  is  especially  noticed  about  the  posterior  molars  when  the 
teeth  are  healthy,  but  is  frequently  obser\^ed  at  the  roots  of  the  lower  incisors, 
since  here  tartar  is  prone  to  collect,  and  hence  the  mucous  membrane  is  more 
Milnerable.  WTien  the  teeth  are  snapped  together,  slight  tenderness  will  be 
noticed.  Close  upon  these  symptoms,  often  preceding  them,  come  distinct 
metallic  taste  in  the  mouth  and  fetor  of  the  breath. 

If  the  drug  is  continued  after  these  symptoms  develop,  and  in  some  cases 
even  though  its  ingestion  be  stopped  at  once,  evidences  of  salivation  become 
even  more  pronounced.  The  gums  are  greatly  swollen  and  ulcerated.  The 
teeth  are  loosened,  the  tongue — indeed,  the  whole  mucous  membrane  of  the 
mouth — becomes  oedematous  and  congested,  and  erosions  and  ulcers  appear 
upon  its  surface.  There  is  an  enormously  increased  flow  of  saliva,  the  sub- 
maxillar}^  and  parotid  glands  are  swollen,  cracks  and  ulcers  appear  at  the  cor- 
ners of  the  mouth,  and  the  breath  is  indescribably  foul.  In  marked  cases  the 
patient  is  unable  to  masticate,  to  swallow,  or  even  to  speak,  and  the  strength 
fails  rapidly. 

In  some  instances  hydrarg>Tism  expends  its  violence  upon  the  alimentary 
canal  and  the  kidneys,  producing  colicky,  bloody  stools,  and  albuminuria.  This 
form  of  poisoning  is,  however,  rare,  save  when  the  h>TDodermic  method  is 
employed. 

Very  exceptionally  acute  mercurialization  appears  in  the  form  of  skin  erup- 
tion. This  develops  as  an  erythema,  a  dermatitis,  or  an  eczema  rubrum,  and 
is  alwaj^s  an  expression  of  idiosjmcrasy. 

Chronic  Hydrargyrism. — In  certain  cases  the  administration  of  mercur\' 
•  seems  to  produce  a  chronic  catarrh  of  the  gastro-intestinal  mucous  membrane. 
The  patient  suffers  from  the  characteristic  symptoms  of  this  condition,  the  appe- 
tite fails,  emaciation  is  progressive,  albuminuria  may  appear,  and  there  is  com- 
plaint of  great  muscular  weakness.  A  profound  gloom  seizes  upon  the  patient, 
or  he  becomes  nervous  and  hysterical.  Since  absolutely  identical  symptoms  may 
be  produced  by  the  disease  for  the  cure  of  which  mercury  is  given,  the  deter- 
mination of  the  cause  of  such  s^-mptoms  is  important. 

When  mercury  has  been  administered  in  comparatively  full  doses  for  a 
long  time,  and  when  such  symptoms  develop  and  are  progressive,  it  is  wise  to 
discontinue  the  specific  drug,  substituting  a  course  of  arsenical  injections  there- 
for, and  to  devote  particular  attention  to  diet,  hygiene,  and  medication  suited 


THE  TREATMENT  OF  SYPHILIS  887 

to  the  cure  of  the  gastro-intestinal  catarrh.  l"he  improvement  following  such 
a  course  of  treatment  forms  the  best  index  to  the  etiology  of  the  symptoms, 
though  this  improvement  is  always  slow. 

When  such  symptoms  develop  in  cases  which  have  been  treated  by  in- 
sufficient doses  of  mercury  it  may 'be  assumed  that  they  are  the  effect  of  syphiUs, 
and  that  on  pushing  the  drug  they  will  probably  disappear.  Albuminuria  may 
be  due  to  mercury  or  to  the  action  of  syphilis.  The  cause  can  be  determined 
only  by  the  therapeutic  test. 

Hydrargyrism  is  said  to  produce  tremblings,  attacks  resembling  epilepsy  or 
apoplexy,  cerebral  palsies  and  anaesthesias,  cephalalgias  and  arthralgias,  dis- 
turbances of  sleep,  vertigo,  and  dementia.  These  symptoms  are  chronic  in  type, 
and  yield  slowly  on  cessation  of  treatment.     Fortunately,  they  are  uncommon. 

Treatment. — Salivation  is  best  avoided  by  minute  attention  to  the  hygiene 
of  the  mouth  and  by  frequent  inspection  of  the  patient,  so  that  the  drug  may 
be  stopped  or  its  dosage  diminished  on  the  development  of  the  first  symptoms. 
WTien  patients  cannot  be  kept  under  observation  they  should  be  told  the  symp- 
toms of  beginning  ptyalism,  and  should  be  instructed  properly  to  regulate  the 
dose  in  the  event  of  such  symptoms  developing.  ,  Daily  hot,  sweating  baths 
constitute  the  most  potent  remedy. 

Potassium  chlorate  is  used  as  a  mouth-wash  in  the  form  of  a  saturated 
aqueous  solution.  A  teaspoonful  of  the  salt  is  added  to  a  glass  of  water,  and 
the  patient  is  instructed  to  rinse  his  mouth  with  this  mixture  every  few  minutes. 

In  alternation  with  this  a  disinfectant  and  astringent  lotion  may  be  employed, 
such  as — 

IJ     Acid,   boric, 

Acid,   tannic,    aaSiv; 
Mel.  rosae,  f  Bii ; 
Aquse,  q.  s.  ad  fSvi. 
M.   S. — Use  as  a  mouth-wash. 

Atropine  should  be  given  in  small  doses,  frequently  repeated,  until  some 
effect  upon  the  pupil  is  noted.  The  drug  may  be  administered  in  powder  form, 
dropped  on  the  tongue,  and  allowed  to  dissolve. 

B     Atropinje  sulphat.,  gr.  -jV ; 

Sacch.   lactis.,    q.   s. 
3.1.    et  ft.  chart,  no.  x. 
S. — One  powder  every  three  or  four  hours. 

In  severe  forms  of  salivation,  ulceration  and  eroded  patches  should  be  touched 
with  five  to  ten  per  cent,  solution  of  silver  nitrate,  and  such  solutions  should 
be  employed  as  hydrogen  peroxide  in  spray  form,  phenol  sodique,  or  potassium, 
permanganate  1  to  1000. 

The  pain  incident  to  taking  food  may  be  allayed  by  painting  the  gums  and 
eroded  patches  with  a  four  per  cent,  solution  of  eucaine  just  before  eating. 

The  elimination  of  mercury  from  the  system  is  materially  hastened  by  pro- 
longed hot-air  or  vapor  baths,  and  by  the  administration  of  diaphoretics,  diu- 
retics, and  laxatives;  the  hot-air  baths  are  the  most  helpful  single  measure. 

If  the  diagnosis  of  chronic  hydrargyrism  is  assured,  withdrawal  of  the  drug 
and  the  inauguration  of  a  tonic  and  stimulating  course  of  treatment  are  indi- 


GENITO-URINARY  SURGERY 

cated.  Change  of  air  and  surroundings  is  particularly  serviceable,  especially 
when  reinforced  by  scrupulous  attention  to  hygiene  and  ferruginous  tonic.  In 
case  mercury  is  subsequently  indicated,  it  should  not  be  administered  by  the 
mouth. 

THE  SYSTEMATIC  TREATMENT  BY  IODIDES 

Potassium  iodide  is  the  preparation  commonly  employed.  The  administra- 
tion of  this  drug  is  rarely  indicated  before  the  end  of  the  second  year,  and  is 
then  given  usually  in  combination  with  mercury.  No  germicidal  effects  can  be 
claimed  for  the  iodides. 

The  commonly  accepted  theory  in  regard  to  their  action  is  that  they  power- 
fully stimulate  the  absorption  of  exudate.  The  lesions  of  late  tertiary  syphilis 
are  particularly  characterized  by  excessive  cell-growth  and  accumulation  of 
imperfectly  organized  tissue,  made  up  for  the  most  part  of  a  small  round- 
cell  infiltrate,  due  to  recrudescence  of  activity  at  the  seat  of  former  disease, 
to  vascular  and  perivascular  lesions,  or  to  a  crippling  or  obliteration  of  lym- 
phatics incident  to  the  long-continued  hyperplasia  of  the  secondary  stage. 
The  cUnical  proof  is  convincing  that  iodides  are  more  potent  than  other 
drugs  in  promoting  fatty  degeneration  and  absorption  of  the  imperfectly 
organized  exudates. 

The  iodides  may  be  satisfactorily  administered  in  sarsaparilla  as  an  ex- 
cipient,  not  because  this  exerts  any  marked  alterative  effect,  but  rather  because 
it  disguises  the  taste  of  the  drug.  The  following  formula  may  be  employed 
in  the  mixed  treatment: 

^     Hydrarg.   iodid.   rub.,  gr.   iv ; 
Potassii  iodidi,  Hss ; 
Syr.  sarsaparillae  comp.,  fBvi. 
M.  S. — Teaspoonful  in  three  ounces  of  water  four  times  daily. 

When  patients  object  to  taking  this  prescription,  the  iodide  may  be  given 
in  the  form  of  saturated  solution,  one  drop  of  which  represents  approximately 
one  grain  of  the  potassium  iodide: 

IJ     Potassii  iodidi,  Si; 
Aquae,  q.  s.  ad  fSi. 
^  S. — Five    to    ten    drops    three   times    a    day    in    half    a    glass    of    milk    or    water, 
increasing  the  number  of  drops  as  required. 

Or  the  iodide  may  be  given  in  the  form  of  compressed  tablets,  mercury 
being  administered  at  the  same  time,  as  previously  directed.  Occasionally 
other  combinations  of  iodine  are  better  tolerated  than  the  potassium  salt,  and 
in  certain  cases  a  combination  of  the  three  best  known  salts  will  be  found  more 
serviceable  than  any  one  administered  singly,  thus: 

R     Potassii   iodidi, 
Sodii   iodidi, 

Ammonii  iodidi,  aa  gr.xcvi; 
Syr.   aurantii  cort.,   fSi ; 
Aquae,  fSv. 
M.    S. — Teaspoonful,    freely   diluted,    four   times    daily. 


THE  TREATMENT  OF  SYPHILIS  889 

When  the  iodide  is  given  in  the  form  of  saturated  solution  the  taste  may  be 
almost  completely  disguised  by  dropping  the  required  dose  in  a  glass  of  milk. 

When  it  disagrees  with  the  stomach, — and  this  is  often  the  case, — it  may  be 
combined  with  essence  of  pepsin  in  the  proportion  of  five  to  ten  grains  in  a 
teaspoonful.  Or  it  may  be  m.ade  into  a  junket,  which  with  proper  seasoning 
completely  hides  the  taste  of  the  iodide.  Moreover,  when  administered  in  this 
manner,  the  stomach  becomes  tolerant  to  a  remarkable  degree.  The  most 
important  practical  point  in  securing  the  fullest  good  effects  of  the  iodides  with 
the  least  harmful  results  is  to  give  them  in  dilute  solution.  The  ordinary  dose 
is  given  in  six  to  eight  ounces  of  water,  and  is  soon  followed  by  another  tum- 
blerful. Hot  water  still  further  facilitates  the  proper  absorption  of  the  drug. 
Iodides  should  be  given  about  an  hour  after  meals.  If  they  occasion  griping 
pains,  tannic  acid  may  be  added  to  the  prescription,  or  the  following  formula 
may  be  used: 

I^     Potassii  iodidi,  Bss  ; 

Syr.  corticis  aurantii,  f§vi. 
M.  S. — A  teaspoonful  in  water  three  times  daily. 

The  iodides  should  be  given: 

1.  For  the  cure  of  gummata,  extensive  diffuse  infiltrations,  vascular  lesions, 
and  those  of  the  central  nervous  system. 

2.  In  precocious  secondary  syphilis, — that  is,  when  the  lesions  resemble  in 
type  those  of  the  tertiary  period,  affecting  the  fibrous  or  connective  tissues,  the 
bones,  the  nerve-centres,  and  important  viscera,  or  when  they  appear  in  the  form 
of  deep  ulcers  or  infiltrations  of  the  skin. 

The  dose  of  the  iodides  is,  as  in  the  case  of  mercury,  greatly  influenced  by 
individual  peculiarity.  Except  when  the  symptoms  are  urgent  and  the  integrity 
of  an  important  organ,  such  as  the  brain,  is  threatened,  the  initial  dose  should 
be  five  grains  three  times  a  day.  This  should  be  increased  by  five  grains  every 
third  day  until  the  symptoms  for  which  the  drug  is  administered  have  dis- 
appeared, or  until  toxic  symptoms  denote  that  the  therapeutic  dosage  has  been 
passed.  The  production  of  the  toxic  symptoms  is  not  indicative  that  the  full 
physiological  or  therapeutic  effects  of  the  drug  have  been  obtained.  To  increase 
the  iodides  until  the  symptoms  are  relieved  sometimes  leads  to  the  administra- 
tion of  enormous  doses,  but  the  evil  effects  of  these  are  usually  far  less  to  be 
dreaded  than  the  results  of  insufficiently  treated  syphilitic  lesions  of  important 
organs.  Thus  pushed,  the  iodides  may  cause  the  disappearance  of  osteocopic 
pains  and  motor  and  sensory  palsies,  and  even  at  times  the  reestablishment  of 
mental  faculties  after  they  have  been  persistently  and  to  all  appearance  hope- 
lessly disordered.  It  should  not  be  forgotten  that  conditions  other  than  those 
caused  by  S}T>hilis  may  be  alleviated  or  cured  by  full  doses  of  the  iodides, 
thus  obscuring  the  value  of  the  therapeutic  test. 

The  alleged  value  of  tolerance  of  iodides  as  a  sign  of  syphilitic  dyscrasia 
is  without  foundation. 

The  value  of  the  iodides  is  so  slight  in  the  ordinary  cases  of  secondary 
syphilis  that  it  is  more  than  counterbalanced  by  their  irritant  effect  upon  the 
respiratory  and  gastro-intestinal  mucous  membranes.  As  a  rule,  their  therapeutic 
value  increases  in  direct  ratio  with  the  age  of  the  syphilis,  but  even  in  early 


890  GENITO-URINARY  SURGERY 

syphilis  the  iodide  should  be  added  to  the  mercurial  treatment  whenever  exten- 
sive and  dense  exudation  has  occurred,  whether  in  the  deeper  layers  of  the 
derm,  in  the  subcutaneous  connective  tissue,  in  the  periosteum  or  bone,  or 
in  the  viscera.  There  is  nothing  more  satisfactory  in  therapeutics  than  the 
direct  and  unmistakable  benefits  following  the  administration  of  the  iodides 
in  such  cases. 

Several  formulae  have  already  been  given  for  the  administration  of  iodides. 
A  saturated  solution  (potassium  iodide,  5i;  water,  q.  s.  ad  5i)  is  the  most  con- 
venient form  in  which  to  administer  the  drug  when  it  is  given  in  ascending 
doses.  In  addition  to  this  preparation  the  patient  may  be  ordered  compound 
syrup  of  sarsaparilla,  to  a  tablespoonful  of  which  the  required  dose  of  iodide 
can  be  added,  the  patient  immediately  afterwards  taking  one  or  two  glasses 
of  water  or  milk.     Free  dilution  is  essential  in  avoiding  gastric  irritation. 

Iron  iodide  is  a  valuable  preparation,  particularly  when  syphilitic  anaemia 
is  marked.     This  may  be  given  either  in  pill  form  or  as  a  syrup. 

The  Toxic  Effects  of  the  Iodides  • 

Under  the  general  heading  iodism  are  included  the  various  toxic  symptoms 
which  may  develop  in  consequence  of  over-dosage  with  this  drug.  Those  com- 
monly observed  are  gastro-intestinal  irritation,  coryza,  pustular  skin  eruption, 
Jachrymation,  tinnitus  aurium,  and  mental  depression.  Exceptionally  neuritis 
and  acute  oedema  of  the  larynx  are  occasioned  by  comparatively  mild  doses  of 
the  iodides. 

As  in  the  case  of  mercury,  iodides  are  most  prone  to  produce  untoward 
effects  in  those  suffering  from  kidney  degeneration. 

The  lesions  of  the  iodide  dermatoses  may  simulate  almost  any  of  the  recog- 
nized forms  of  acute  cutaneous  eruption.  They  commonly  appear  in  the  form 
of  acne,  but  erythema,  eczema,  and  herpes  are  by  no  means  rare.  Purpura  is  fre- 
quently observed,  and  even  sloughing,  gangrenous  ulcers  are  occasionally  noted. 

These  eruptions  are  due  to  idiosyncrasy  and  bear  no  definite  relation  to  the 
dose  employed.  In  some  instances  small  doses  produce  toxic  effects;  in  others 
heroic  doses  are  taken  with  impunity. 

In  the  dose  ordinarily  employed  in  the  treatment  of  syphilis  a  large  pro- 
portion of  patients  will  exhibit  no  symptoms  whatever  from  the  use  of  the 
iodides.  A  larger  proportion  will  be  troubled  with  a  coppery  taste  in  the  mouth 
and  with  an  acneiform  eruption,  affecting  the  face  by  preference,  but  often 
widely  distributed.  Coryza,  lachrymation,  slight  conjunctivitis,  and  symptoms 
of  indigestion  incident  to  gastro-intestinal  catarrh  are  also  common.  A  very 
small  percentage  of  the  cases  will  suffer  from  swelling  of  the  mucous  membrane 
of  the  larynx  and  pharynx,  sometimes  so  great  as  to  endanger  life,  and  from 
an  especially  severe  skin  eruption  much  like  furunculosis,  which  may  go  on  to 
the  purpuric  or  the  sloughing  form. 

Treatment. — The  treatment  of  iodism  depends  upon  the  severity  of  the 
symptoms.  In  the  milder  cases,  and  particularly  when  it  is  important  to 
continue  administering  the  drug  for  the  purpose  of  effecting  resolution  and 
absorption  of  syphilitic  deposits,  the  iodide  may  be  continued,  or  the  dose  may 
be  slightly  increased,   since  in  most   cases  tolerance   is  established   and  the 


THE  TREATMENT  OF  SYPHILIS  891 

coryza  and  eruption  disappear.  A  few  drops  of  Fowler's  solution  may  be 
administered  together  with  the  iodides.  The  gastro-intestinal  symptoms  are 
controlled  by  carefully  regulating  the  diet,  administering  slightly  astringent  and 
antiseptic  digestive  powders,  and  giving  the  iodides  largely  diluted,  preferably 
in  milk  to  which  essence  of  pepsin  has  been  added.  Or,  if  this  method  is  not 
feasible,  each  dose  of  the  drug  should  be  dissolved  in  a  full  glass  of  soda-water, 
flaxseed  tea,  or  other  bland  excipient. 

Vegetable    Infusions    and    Decoctions 
These  are  sometimes  useful  as  adjuvants  in  the  treatment  of  syphilis,  but 
have  no  specific  action  of  their  own.    The  two  best  recognized  are  the  following: 

Succus  alterans    (McDade's   Formula). 
I^  Ext.  smilacis  sarsaparillae  fl., 
Ext.   stillingicC   sylvat.   fl., 
Ext.  kappae  minoris  fl., 
Ext.  phytolaccje  decand.  fl.,   aa   fsii; 
Tinct.  xanthoxyli   carolin.,    f3i. 
M.  S. — Take  a  teaspoonful  in  water  three  times  a  day  before  meals,  and  gradually 
increase  to  tablespoon  doses. 

This  may  be  employed  in  alternation  with  the  mixed  treatment  where  daily 
dosing  of  the  latter  cannot  be  borne. 

When  the  appetite,  digestion,  or  nutrition  needs  attention,  the  .following 
tonic  is  useful: 

B.   Strychninae  sulphat.,  gr,  i; 
Acid,  phosphoric,  dil.,  f3iii; 
Liq.  pepsinse,  q.  s.  ad  fSvi. 
!M'.  S. — One  teaspoonful  in  water  after  each  meal  and  before  going  to  bed. 

Zittmami's  treatment  of  intractable  syphilis  has  for  its  underlying  principle 
elimination  by  diaphoresis  and  purgation. 

The  evening  before  the  treatment  is  begun,  the  patient  receives  two  pills,  each 
containing  two  grains  of  calomel,  five  grains  of  compound  extract  of  colocynth, 
and  two  grains  of  extract  of  hyoscyamus.  The  remainder  of  the  treatment  con- 
sists in  the  use  of  two  decoctions.  The  first  contains  sarsaparilla  root  four 
ounces,  anise-  and  fennel-seed  each  five  hundred  grains,  senna  leaves  one  ounce, 
and  liquorice  root  four  ounces;  these  are  bruised  and  added  to  four  gallons 
of  water,  together  with  eighty  grains  each  of  white  sugar,  alum,  and  calomel, 
and  twenty  grains  of  the  red  sulphide  of  mercury  enclosed  in  a  linen  bag; 
the  water  is  then  boiled  down  gently  to  one  gallon.  This  is  decanted  and 
constitutes  Decoction  Xo.  1.  Its  dregs  are  put  into  three  gallons  of  water, 
with  two  ounces  of  sarsaparilla  root,  and  one  ounce  each  of  lemon-peel,  carda- 
mom seed,  and  liquorice  root,  and  boiled  down  to  one  gallon.  This  constitutes 
Decoction  Xo.  2. 

The  morning  after  taking  the  purgative  pills,  and  each  day  after  this,  the 
patient  drinks  half  a  pint  of  hot  decoction  X'o.  1  at  nine,  ten,  eleven,  and  twelve 
o'clock,  and  in  the  evening  half  a  pint  of  cold  decoction  X"o.  2  at  three,  four, 
five,  and  six  o'clock.  He  is  kept  in  bed  except  for  one  hour  each  evening.  On 
the  fifth  day  he  takes  a  hot  bath  and  is  allowed  to  dress.  On  the  evening  of 
the  fifth  day  two  of  the  above  pills  are  again  administered,  and  the  next  day 
the  routine  treatment  is  resumed.    The  whole  course  lasts  fifteen  days. 


892  GENITO-URINARY  SURGERY 

LOCAL  TREATMENT  OF  SYPHILIS 

The  Chancre. — Intravenous  treatment  with  salvarsan  or  neosalvarsan 
promptly  cures  the  chancre.  The  surface  of  the  ulceration  should  be  kept  clean 
by  means  of  antiseptic  sprays  or  washes,  to  avoid  mixed  infection,  and  there- 
after dusted  with  zinc  stearate  and  calomel,  equal  parts  by  weight  of  each;  or, 
if  the  inflammation  be  acute,  the  sore  should  be  wet  dressed  every  two  hours, 
two  per  cent,  boric  solution  or  four  per  cent,  sodium  chloride  answering  well. 

When  there  is  a  tendency  to  form  crusts,  salves  are  useful: 

IJ.     Emplast.   hydrarg., 

Cerat.  resin.,  aa  Bss. 
M.  S.— Use  locally. 

IJ     Zinci   oxidi,  gr.  v; 

Ac.  borici,  gr.  xl; 

Petrolati,  q.  s.  §i. 
M.  S.— Use  locally. 

If  the  granulations  are  sluggish,  touching  with  a  five  per  cent,  silver  nitrate 
solution  is  desirable. 

When  the  chancre  is  covered  by  a  tough  pseudo-membrane,  beneath  which 
ulceration  is  extending,  probably  from  the  reaction  of  the  ordinary  pus-microbes, 
destructive  cauterization  may  be  necessary.  Nitric  acid  or  acid  mercuric 
nitrate  may  be  employed,  the  surrounding  tissues  being  protected  by  oiled 
cotton;  antiseptic  forhentations  should  follow. 

Gangrenous  and  phagedaenic  chancres  require  the  same  local  applications,  or 
the  actual  cautery,  supplemented  by  tonic  and  supportive  treatment. 

Of  the  dry  powders,  zinc  stearate  is  the  most  serviceable.  It  may  be  admin- 
istered pure  or  mixed  with  powdered  boric  acid,  calomel,  or  starch.  Calomel 
may  also  be  mixed  with  an  equal  quantity  of  lycopodium.  Dermatol  is  an 
astringent,  healing  antiseptic,  free  from  irritating  properties  and  devoid  of 
unpleasant  odor.  It  may  be  used  either  as  a  powder  or  as  an  ointment.  Aristol 
is  also  serviceable.  The  dry  powder  is  inert,  hence  it  should  be  dusted  on  the 
surface  of  the  lesion  and  a  drop  of  olive  oil  allowed  to  fall  on  it  from  a  glass 
rod;  it  should  then  be  covered  immediately  with  some  thin,  impermeable  sub- 
stance, under  which  solution  takes  place  slowly.  No  cotton  or  charpie  should 
be  applied  to  the  ulcer.    The  dressing  should  be  renewed  twice  daily. 

To  chancres  not  covered  by  crusts  or  pseudo-membrane  and  exhibiting  but 
slight  inflammatory  reaction,  flexible  collodion  may  be  applied. 

To  urethral  and  rectal  chancres  iodoform  in  the  shape  of  suppositories  may 
be  applied  after  copious  flushing  wath  dilute  corrosive  chloride  solution  (1  to 
10,000).  These  suppositories,  made  of  cacao  butter  or  gelatin  and  of  appro- 
priate shape  and  size,  should  contain  from  two  to  five  grains  of  iodoform.  Gray 
ointment  diluted  with  three  parts  of  vaseline  is  also  serviceable  in  the  local  treat- 
ment of  these  lesions. 

Chancres  of  the  tongue,  mouth,  or  tonsils  are  treated  by  frequent  gargling 
with  cleansing  and  nonirritating  mouth-washes,  and  local  applications  of  silver 
nitrate  solution  (1  to  10). 

The  Syphiltdes. — Skin  lesions  may  be  benefited  by  applications  of  mer- 
cury to  the  surface  and  the  systematic  employment  of  hot  baths. 


THE  TREATMENT  OF  SYPHILIS  893 

Erythematous  syphilides  usually  require  no  local  applications.  When  they 
are  sufficiently  persistent  and  conspicuous  to  demand  treatment,  the  following 
formulae  will  be  found  useful: 

IJ     Hydrarg.  chloric!,  mit.,  3i ; 
Unguent,   zinci  oxidi, 
Unguent,  petrolei  carbolat.,  aa  5ss. 

M.  et    ft.   ung.      S. — Apply   locally. 

3    Hydrarg.  chlorid.  mit., 
Pulv.  amyli,  aa  Si. 

M.  S. — Dust  lightly  over  the  parts  affected. 

Papular  syphilides  are  often  obstinate,  and  are  especially  benefited  by  ( 1 ) 
vapor  baths;  (2)  inunction  and  massage;  (3)  ointments  containing  mercury 
in  one  of  the  following  formulae: 

IJ    Ung.   hydrarg.  nitrat., 

Ung.  petrolei  carbolat.,  aa  Ess. 

B     Hydrarg.  ammoniat.,   Si; 
Unguent,  aquse  ros.,  5i. 

These  ointments  are  especially  serviceable  in  the  papulo-squamous  eruptions. 
When  these  attack  the  hand,  a  region  in  which  they  are  persistently  recurrent, 
the  local  vapor  bath  proposed  by  Wells  is  particularly  efficacious.  The  interior 
of  an  inverted  hat-box  is  filled  with  calomel  vapor  by  means  of  a  small  alcohol 
lamp  placed  beneath  a  metal  dish  containing  calomel,  and  the  hand  is  intro- 
duced within  the  box  through  a  hole  cut  in  the  side. 

Mucous  Patches. — These,  for  the  most  part,  may  be  prevented  from 
appearing  in  the  mouth  by  taking  the  precautions  already  mentioned  (p.  870). 
When  they  appear,  they  should  be  painted  two  or  three  times  daily  with  a  one 
to  ten  per  cent,  solution  of  silver  nitrate,  or  touched  with  the  solid  stick,  and 
an  antiseptic  mouth-wash  should  be  used,  such  as  the  following: 

R    Acid,  boric, 

Acid,   tannic,  aa   9ii; 
Mel.  ros.,   fSii; 
Aquas,  fSvi. 

M.  S.^Use    as    a    mouth-wash. 

Or  sprays  of  listerine,  Dobell's  solution,  or  hydrogen  peroxide  may  be  employed. 
Iodine,  applied  to  the  lesions,  is  stimulating  and  resolvent: 

^    lodi, 

Potassii   iodidi,  aa  Bii ; 
Glycerini,  q.  s.  ad  fSi. 

M.  S.— Apply   locally. 

The  scaly  patches  should  be  touched  every  second  or  third  day  with  ten 
per  cent,  chromic  acid  solution  or  acid  mercuric  nitrate  half  strength.  If  they 
still  persist,  they  should  be  removed  by  the  sharp  curette  or  the  actual  cautery. 

Ulcerated  patches  in  the  throat  are  benefited  by  the  same  treatment;  cleans- 


894  GENITO-URINARY  SURGERY 

ing   sprays  are  particularly   serviceable.     In   addition,   fumigations   may  be 
administered,  as  advised  by  Mauriac: 

IJ     Hydrarg.  iodidi  vir.,  3ss; 

Carb.  lig.,  Siss; 

Benzoin.,  gr.  viiss; 

Aquas,  q.  s. 
M.  et  ft.  trochisci  no.  xx. 

S. — One  to  be  burned  morning  and  night,  and 
the  vapor  inhaled. 

The  use  of  tobacco  must  be  given  up  entirely,  and  the  mouth  kept  scrupu- 
lously clean. 

Condylomata,  if  vegetating  and  exuberant,  should  be  cauterized  with  nitric 
acid,  acid  mercuric  nitrate,  or  chromic  acid.  These  last  two  drugs  may  produce 
toxic  symptoms.  Indeed,  death  has  resulted  from  the  topical  application  of  the 
latter:  hence  it  should  not  be  applied  to  a  large  surface. 

IJ    Acid,   chromic,   3ii; 

Aquse,    f§iii. 
M.  S.— 'Apply  locally,  to  a  limited  area. 

The  vegetations  may  also  be  destroyed  by  the  use  of  the  following  mixture: 

li    Plumbi  oxidi,  gr.   iv; 

Liq.  potass,  caust.  (33  per  cent.),  TTLcxvi. 
]\I.  S. — Caustic.     For  external  use  only. 

A  single  application  is  usually  efficient;  sometimes  two  or  three  applications 
are  required  at  intervals  of  two  or  three  days.  After  this  caustic  is  applied,  the 
affected  surface  is  dusted  with  stearate  of  zinc.  A  cicatrix  forms  in  from  three 
to  ten  days. 

Small  lesions  disappear  after  painting  with: 

IJ     Acidi  salicylici,  gr.  xxx ; 

Collodion    (flexilis),  Si.     M. 

Mild  cases  require  no  local  treatment  beyond  cleanliness,  drying,  and  dusting 
with  calomel. 

When  the  papillary  overgrowth  is  extensive,  it  should  be  removed  by  the 
cautery  knife,  the  resulting  raw  surface  being  closed  by  skin  transplantation 
if  necessary. 

Pustular  and  Pustulo-Crustaceous  Syphilides. — It  is  particularly  in 
this  class  of  cases  that  the  mercury  and  vapor  baths  are  serviceable,  supple- 
mented by  the  calomel  and  zinc  ointment  (see  p.  888).  The  latter  may  be 
used  on  the  face  at  bedtime.  When  the  ulcerations  are  indurated  and  crusted 
the  following  prescriptions  may  be  used: 

15  Hydrarg.  bichlorid.,  gr.  ii ; 
Unguent,  hydrarg.  nitratis, 
Ung.  petrolei  carbolat.,  aa  5ss. 

B  Hydrargyri  oxidi  rub..  3ii; 
Unguent,  zinci  oxidi,  3yi. 


THE  TREATMENT  OF  SYPHILIS  895 

Leg  ulcers  should  be  cleansed,  strapped,  and  bandaged.  If  they  refuse  to 
heal  under  this  treatment,  the  whole  surface  and  the  surrounding  skin  may- 
be covered  in  with  a  piece  of  thinly  spread  plaster  containing  equal  parts  of 
emplastrum  hydrargyri  and  emplastrum  cerati;  over  this  is  applied  a  tight 
bandage  which  includes  the  foot  and  leg.  Dressings  should  be  repeated  in 
accordance  with  the  amount  of  discharge. 

Tubercular  Syphilides,  Gummata,  and  Periosteal  Nodes,  when  non- 
ulcerated,  may  best  be  treated  locally  by  the  continuous  application  over  their 
surface  of  the  following  ointment  spread  on  a  piece  of  lint: 

li    Ung.  iodi  comp.,  3i; 
Ung.  belladonnse,  3ii; 
Ung.  hydrarg.,  3iii ; 
Ung.  petrolei  carbolat.,   3iv. 

This  ointment  may  be  combined  with  the  local  use  of  heat,  a  hot-water 
bag  being  applied  to  the  lesion  for  as  many  hours  a  day  as  is  practicable. 

Chronic  persistently  spread  serpiginous  ulceration  should  be  treated  by  the 
prolonged  bath — days  or  weeks  if  necessary.  If  this  fails,  the  actual  cautery  is 
indicated. 

Ulcerations  are  curetted,  cleansed,  and  treated  on  general  principles.  Cari- 
ous and  necrosed  bones  should  be  subjected  to  appropriate  surgical  measures. 

In  a  few  reported  cases  obstinate  ulcerating  syphilitic  lesions  which  resisted 
specific  treatment  recovered  promptly  after  an  attack  of  erysipelas.  There  has 
been  no  formal  effort,  however,  to  utilize  this  fact  in  the  treatment  of  such 
lesions. 

THE  TREATMENT  OF  HEREDITARY  SYPHILIS 

The  treatment  of  inherited  syphilis  may  be  considered  under  the  following 
heads: 

1.  The  prophylactic  treatment  of  the  parents  before  conception; 

2.  The  treatment  of  the  mother  during  pregnancy; 

3.  The  treatment  directed  to  the  child. 

1.  The  prophylactic  treatment  before  conception  is  that  already  de- 
scribed as  appropriate  to  syphilis,  except  that  more  attention  is  paid  to  the 
general  hygiene  applicable  to  the  sexual  relations,  and  every  effort  is  made  to 
suppress  by  full  doses  of  arsenic  and  mercur}^  any  manifestation  of  active 
syphilis  and  to  maintain  a  persistent  negative  Wassermann. 

Probably  the  most  important  point  in  prophylaxis,  so  far  as  the  practitioner 
is  concerned,  is  his  advice  in  regard  to  marriage,  or,  if  this  has  already  been  con- 
summated, in  regard  to  preventing  conception  from  taking  place. 

Consent  to  marry  may  be  given  to  patients  who  have  been  actively  treated 
and  whose  Wassermann  has  been  consistently  negative  for  two  years.  WTien 
syphilis  has  been  contracted  after  marriage  the  same  conditions  should  obtain 
regarding  the  bearing  of  children. 

When,  in  spite  of  due  warning,  or  perhaps  from  lack  of  it,  marriage  has 
taken  place  and  the  sexual  relations  are  established,  active  treatment  of  the 
mother  is  imperative. 


896  GENITO-URINARY  SURGERY 

2.  The  Treatment  of  the  Mother. — Whether  the  mother  is  previously 
syphilitic,  or  has  conceived  by  a  syphilitic  husband,  or  has  contracted  the  dis- 
ease after  impregnation,  she  is  treated  in  accordance  with  the  principles  already 
laid  down.  Mercury  and  arsenic  are  pushed  and  are  advantageously  combined 
with  moderate  doses  of  potassium  iodide.  Special  care  must  be  taken  not  to 
allow  the  medication  to  produce  gastro-intestinal  irritation,  since  this  strongly 
predisposes  to  the  production  of  abortion.  When  the  mother  is  thus  treated  she 
will  probably  bear  a  living  child,  and  one  either  healthy  or  exhibiting  syphilis 
in  a  mild  form. 

3.  The  Treatment  of  the  Chh-d  after  Birth. — Since  the  pathology, 
stages,  and  general  course  of  hereditary  syphilis  are  similar  to  those  of  the 
acquired  disease,  treatment  is  conducted  on  the  plan  already  described. 

In  hereditary  sj^hilis  the  treatment  is  modified  somewhat  by  the  following 
considerations: 

1.  There  is  always  a  more  or  less  profound  cachexia  influencing  all  the 
nutritive  and  formative  processes,  and  in  itself,  aside  from  specific  lesions  of 
vital  organs,  threatening  life. 

2.  During  the  secondary  period  lesions  corresponding  to  the  tertiary  type, 
particularly  gummata,  are  frequent. 

The  cachexia  and  its  results  are  combated  by  supplementing  the  specific 
treatment  by  one  which  is  stimulating  and  supporting.  Special  attention  should 
be  paid  to  the  nutrition.  The  nurse  of  the  child  should,  of  course,  be  its 
mother,  since  it  cannot  convey  the  disease  to  her.  If  the  child  cannot  be  fed 
at  the  breast,  its  chances  for  survival  are  greatly  reduced.  The  selection  of  the 
most  nutritious  and  easily  digested  artificial  food  then  becomes  a  matter  of 
cardinal  importance.  Tonic  treatment  should  be  employed,  iron  iodide,  cod- 
liver  oil,  and  preparations  of  the  hypophosphites  being  most  useful. 

Routine  Treatment  of  Hereditary  Syphilis 
The  children  of  syphilitic  parents  may  exhibit  characteristic  lesions  at  birth ; 
they  may  remain  apparently  healthy  for  several  weeks  and  then  suffer  from 
typical  secondaries;    or   they   may   remain  free  from  signs  or   symptoms  of 
syphilis  through  life. 

When  a  child  shows  characteristic  manifestations  of  the  disease  at  birth, 
immediate  treatment  is  indicated. 

When  an  apparently  healthy  child  is  born  of  syphilitic  parents  and  exhibits 
a  negative  Wassermann  the  indications  are  not  so  clear,  since  there  is  no  cer- 
tainty that  the  disease  will  ever  develop.  As  a  rule,  it  is  safe  to  wait  for 
characteristic  symptoms  or  a  positive  Wassermann.  An  apparently  healthy 
child  with  a  positive  Wassermann  should  be  treated  in  accordance  with  the 
principles  applicable  to  a  syphilitic  adult,  the  neosalvarsan  and  mercury  being 
given  in  small  doses  ^4  to  1  grain  of  mercury  with  chalk,  or  7^^  grains  of 
mercurial  ointment;  0.001  to  0.004  gramme  neosalvarsan  for  each  pound  of 
body  weight).  Neosalvarsan  has  been  injected  into  the  external  jugular  veins 
and  veins  of  the  scalp,  made  prominent  by  the  child's  crying,  and  into  the 
superior  longitudinal  sinus,  through  the  anterior  fontanelle.  When  parental 
syphilis  is  recent,  and  has  not  received  appropriate  treatment,  the  child  should 


THE  TREATMENT  OF  SYPHILIS  897 

be  given  the  specifics  without  waiting  for  symptoms  or  the  serological  reaction. 

The  routine  method  of  treatment  is  as  follows:  four  neosalvarsan  intravenous 
injections,  the  drug  being  dissolved  in  a  minimal  amount  of  sterile  distilled 
water,  at  intervals  of  two  weeks.  The  fourth  day  following  injection  the  sur- 
face of  the  child's  abdomen  is  bathed  with  Castile  soap  and  water,  then  with 
a  saturated  solution  of  boric  acid,  after  which  it  is  thoroughly  dried.  Mercurial 
ointment  diluted  with  three  parts  of  vaseline  is  then  spread  on  the  child's 
binder,  and  the  latter  is  applied  as  usual  in  infants.  Half  a  drachm  of  this 
dilute  ointment  may  be  used  daily.  After  the  binder  has  been  worn  for  twenty- 
four  hours  the  abdomen  is  again  washed  with  soap  and  water,  followed  by 
boric  acid  solution;  a  half-drachm  of  the  ointment  is  then  rubbed  into  the  skin, 
and  the  binder  previously  employed  is  again  applied.  This  binder  is  changed 
for  a  fresh  one  every  fourth  day.  The  dose  is  regulated  by  its  effect  on  the 
symptoms,  if  any  be  present,  otherwise  to  keep  well  within  the  limit  of  affected 
nutrition.  After  the  last  dose  of  neosalvarsan,  in  the  absence  of  clinical  mani- 
festations and  with  a  negative  Wassermann,  no  further  treatment  is  needed. 
A  persistently  positive  Wassermann  calls  for  repetitions  every  six  months  for 
two  years;  thereafter  a  mercurial  treatment  spring  and  fall  for  life. 

Should  the  prolonged  application  of  the  ointment  produce  dermatitis,  the 
inflamed  skin  may  be  bathed  with  witchhazel  and  dusted  with  zinc  stearate, 
carbolized  talc,  or  other  healing  powder,  the  mercury  then  being  administered 
in  the  form  of  inunctions,  which  are  rubbed  into  the  back,  sides,  and  front  of 
the  chest,  and  the  arms,  thighs,  and  legs,  a  fresh  skin  surface  being  chosen 
each  day. 

Exceptionally,  mercurial  ointment,  even  though  used  in  this  way,  occasions 
so  much  local  reaction  that  its  surface  application  must  be  abandoned. 

When  treatment  by  the  mouth  must  be  resorted  to,  probably  the  most 
efficient  formula  is  the  following: 

R     Hydrarg.   cum.   creta,  gr.   i-xii; 

Sacch.  alb.,  gr.  xii. 
M.  et.  div.  in  chart,  no.  xii. 

S. — One  powder  three  times  a  day;  to  be  taken 
soon  after  nursing. 

Externally,  at  the  same  time,  a  mild  mercurial  ointment  may  be  used,  or, 
better,  the  following  may  be  kept  in  contact  with  the  skin  under  pressure: 

!?■    Ung.  hydrarg., 

Ung.  zinci  oxidi,  aa  Sss ; 
Bals.  Peru.,  3i.     M. 

In  conjunction  with  inunctions  or  the  internal  use  of  the  powders  of  mercury 
with  chalk,  potassium  iodide  may  be  given  in  a  syrupy  solution,  in  doses  varying 
from  half  a  grain  to  a  grain,  or,  if  there  be  any  marked  tertiary  symptoms, 
even  in  much  larger  doses,  three  or  four  times  daily. 

Occasionally  nothing  whatever  will  be  retained  by  the  stomach.  Under 
such  circumstances  intramuscular  injections  are  indicated.  These  injections 
are  open  to  the  same  objections  as  obtain  against  this  method  in  the  adult.  They 
are,  however,  often  to  be  preferred  to  internal  treatment,  and  should  be  admin- 
istered in  the  manner  already  described. 
57 


898  GENITO-URINARY  SURGERY 

The  solution  of  choice  is  the  one  per  cent,  sublimate  mixture  (see  p.  1880). 
Beginning  with  a  dose  of  one  minim  (one-hundredth  of  a  grain)  every  second 
day,  the  quantity  injected  is  gradually  increased  to  two,  three,  or  four  minims. 

In  addition  to  the,  medicinal  treatment,  special  attention  should  be  paid  to 
cleanliness  and  hygiene.  If  possible,  the  life  should  be  out  of  doors,  and  the 
food  should  be  healthy  and  invigorating. 

The  indirect  treatment  of  the  child — i.e.,  the  administration  of  specific  medi- 
cine to  the  nursing  mother — is  of  possible  utility  when  other  methods  have 
failed  or  must  be  temporarily  interrupted. 

TREATMENT  OF  SYPHILIS  OF  THE  CENTRAL  NERVOUS 

SYSTEM 

Based  on  the  fact  that  neither  mercury  nor  arsenic,  except  in  infinitesimal 
quantities,  can  be  recovered  from  the  cerebrospinal  fluid,  after  being  given  in 
the  usual  way,  and  that  hence  neither  drug  can  exert  its  inhibiting  or  destructive 
influence  on  the  spirochaetes  lodged  and  multiplying  in  the  central  nervous 
system  or  its  envelopes,  there  has  been  developed  a  method  of  subdural  medi- 
cation, particularly  in  regard  to  arsenic,  which,  seen  through  the  eyes  of  indi- 
vidual enthusiasts,  has  been  singularly  efficacious  in  the  treatment  of  the  late 
tertiaries,  particularly  when  manifested  in  the  form  of  paresis  or  locomotor 
ataxia,  or  both.  To  unprejudiced  observers  there  is  as  yet  no  convincing  proof 
that  such  injections  are  helpful.  These  chronic  maladies  are  subject  to  astonish- 
ing exacerbations  and  remissions  without  assignable  cause,  are  nearly  always 
helped  by  general  hygienic  supervision,  and  particularly  by  attention  to  elimina- 
tion. The  intraspinal  treatment  has  usually  been  supplemented  by  intravenous 
injections;  the  improvement  noted  has  not  been  greater  than  that  observed  after 
other  methods,  including  those  supposed  to  be  specific  and  those  which  are 
certainly  not  so.  In  the  light  of  present  knowledge,  resort  should  not  be  had 
to  intraspinal  medication  so  long  as  improvement  clinically  or  in  the  char- 
acter of  the  blood  and  spinal  fluid  is  manifested  from  intravenous  therapy. 
If  the  patient's  condition  becomes  stationary,  and  is  unsatisfactory,  and  the 
spinal  fluid  still  exhibits  abnormalities,  as  shown  by  the  laboratory  tests,  despite 
intensive  intravenous  arsenic  therapy  in  conjunction  with  the  efficient  use  of 
mercury  and  the  iodides,  intraspinal  medication  by  autosalvarsanized  or  sal- 
varsanized  autosalvarsanized  serum  may  be  considered  in  selected  cases  of 
early  tabes  dorsalis. 

Swift  and  Ellis  give  a  full  dose  of  salvarsan  or  neosalvarsan  intravenously, 
drawing  off  40  c.c.  of  blood  one  hour  later.  This  is  clotted,  centrifuged,  and 
the  clear  fluid  pipetted  off.  Twelve  cubic  centimetres  of  this  serum  are  diluted 
with  18  cubic  centimetres  of  normal  salt  solution,  heated  in  a  water-bath  at 
56°  C.  for  one-half  hour,  and  introduced  subdurally  by  lumbar  puncture. 
Swift  does  not  find  it  necessary  at  present  to  dilute  the  serum  as  at  first 
recommended. 

Wile  injects  a  watery  solution  of  neosalvarsan;  the  contents  of  a  0.3-gramme 
ampoiile  is  dissolved  in  5  cubic  centimetres,  of  recently  distilled  water  and  from 
one  to  three  drops  (3  to  9  mg.)  of  this  are  given  at  a  dose.     The  quantity  of 


THE  TREATMENT  OF  SYPHILIS  899 

solution  to  be  used  is  first  drawn  into  a  syringe,  the  latter  being  then  attached 
to  the  lumbar  puncture  needle  through  which  cerebrospinal  fluid  is  flowing. 
The  syringe  (10  cubic  centimetres)  is  first  sucked  full  of  this  fluid,  thus  diluting 
the  arsenical  solution,  and  the  whole  is  then  gently  injected  subdurally.  After 
the  injection  the  hips  of  the  patient  are  raised  higher  than  his  head  and  so  held 
for  one  hour.  Ogilvie  recommends  for  intraspinal  injection  the  addition  of 
salvarsan  or  neosalvarsan  directly  to  the  patient's  serum,  and  this  method  is 
preferred  by  Fordyce  as  follows:  To  8  or  10  c.c.  of  the  patient's  serum,  free 
of  red  blood-cells,  is  added  0.05  to  0.5  mg.  of  salvarsan  and  the  solution  is 
incubated  at  37°  C.  for  half  an  hour,  prior  to  intraspinal  injection.  Swift 
recommends  that  the  serum  of  the  salvarsanized  patient  be  used  for  this 
patient. 


INDEX 


Abscess,  perinephric,  646 
location,  646 
primary,  645 
secondary,    646 

periprostatic,  390 
treatment  of,  390 

peri-urethral,  231 
gonorrhoeal,  230 
treatment,  232 

prevesical,  501 

diagnosis    and    prognosis   of,    502 
symptoms  of,  502 
treatment  of,  502 

prostatic,  233 

of  suprarenal   glands,  683 

of  testicle,  326 
Absence  of  penis,  94 

of  urethra,  143 
Acid-fast  bacteria,  19 
Acmi  cystoscope,  35 
Acne,  syphilitic,  739 
Actinomjxosis,  renal,  650 
Adenitis,   urethral,   treatment  of,   208 
Adenoma  of  kidney,  672 

of  testicle,  335 
Agglutinins,  86 
Albuminuria  in  renal  tuberculosis,  655 

syphilitic,  843 

in  urethritis,  posterior,  190 
Alcoholism,   cause  of  rupture   of   blad- 
der, 481 
Algolagnia,  462 

Alopascia,  syphilitic,  719,  756,  833 
Amyloid  degeneration  of  liver,  771 
Anaesthesia,  sexual,  461 
Analgesia,  syphilitic,  720 
Anatomy  of  bladder,  465 

of  kidneys,  586 

of  penis,  91 

of  prostate,  381 

of  scrotum,  290 

of  seminal  vesicles,  300 

of  spermatic   cord,  364 

of  testicles,  297 

of  ureters,  560 

of  urethra,  139 

of  vas  deferens,  299 
Androgyny,  464 
Aneurism  of  renal  artery,  617 
Angina,  acute  syphilitic,  718 
Angioma  of  bladder,  547 

of  kidney,  672 

of  penis,  131 
Animal  inoculations,  20 


Anomalies  of  kidney,  590 
Anorchism,  300 
Antibodies,  86 
Antigens,  846 

nature  of,  846 

syphilitic,    preparation    of,    850 
Antipyrine,  use  of,  in  hasmaturia,  10 
Antitoxins,  86 
Anuria,  calculus,  622 
treatment  of,  623 
after  nephrectomy,  617 
non-obstructive,  58 
obstructive  treatment  of,  58 
Anus,  syphilis  of,  772 
Applications  and  operations,  topical,  37 
Ardor  urinse,  189 
Argyll-Robertson  pupil,  786 
Argyrol,    use    of,    in    chancroid,    124;    in 
gonorrhoea,  198 
in  acute  posterior  urethritis,  264 
Arteries,  cerebral,  syphilis  of,  777 

syphilis  of,  813 
Arthralgia,  syphilitic,  809 
Arthritis,  gonorrhoeal,  241 

gonorrhoeal  rheumatism,  differen- 
tiation from,  242 
hydrarthrosis  in,  241 
symptoms,  241 
treatment,  242 

bacterin  therapy,  243 

Bier's  hyperasmia,  243 

expectant,  242 

physiological      and      biological 

therapy,  243 
serum  therapy,  243 
surgical,  242 
gummatous,  809 
Aspermia,  451 
Aspiration  of  bladder,  75 
hydronephrosis,  667 
Atony  of  bladder,  475 
Atresia  of  urethra,  143 

treatment  of,  143 
Atrophia  neonatorum,  829 
Atrophy  of  bladder,  475 
of  prostate,  427 
of  testicle,  301 
Azoospermia,  452 

from  X-ray  exposure,  452 

Bacillus  of  Ducrey,  113 
Bacteria,  acid-fast,  staining  of,  19 
in  urine,  19 


902 


INDEX 


Bacterin  therapy,  86,  88 
dosage  in,  87 
indications  for,  88 
in  kidney  diseases,  88 
in  diseases  of  prostate,  88 
in  diseases  of  seminal  vesicles,  88 
in  urethral  conditions,  213 
in  urethritis,  88 
in  vulvovaginitis,  88 
Bacterins,  86 
Bacteriolysins,  86,  846 
Balanitis,  108  • 

causes  of,  108 
diagnosis  of,  110 
gonorrhoeal,  228 
symptoms  of,  109 
treatment  of,  110 
Balanoposthitis,  108 
causes  of,  108 
chanchroidal,  110 
treatment  of.  111 
diagnosis  of,  110 
gonorrhoeal,  228 
infecting,  698 
paraphimosis  in,  101 
sequelae  of,  109 
syphilitic,  110 
treatment  of,  110 
Ballottement,  renal,  676 
Bartholinitis,  219 
acute,  219 
chronic,  226 
treatment,  220 
Bartholin's  glands,  173 
Beck's  graft  method,  150 
Bier's   hypersemia,   243 
Bigelow's  lithotrite,  518 
Bilharzia,  489 

diagnosis  of,  490 
cystoscopic,  49 
Bevan's    operation    for    cryptorchidism, 

308 
Bladder,  absence  of,  468 

accessibility  for  exploration,  468 
anatomy  of,  465 
apex  of,  465 
aspiration  of,  75 
atony  of,  475 
diagnosis  of,  475 
treatment  of,  476 
atrophy  of,  475 

bacterin  therapy  in  diseases  of,  88 
blood  in,  47 
blood-vessels  of,  467 
body  of,  465 
calculus  of   (see  Calculus,  Vesical), 

507 
cancer  of,  549 
congestion  of,  488 


Bladder,  congestion  of,  causes  of,  488 
contusions   of,  477,  478,  480 
diagnosis  of,  480 
symptoms  and  treatment  of,  480 
exstrophy  of,  469 

morbid   anatomy,  469 
fistula  of,  485 

diagnosis    of,   486 
intestinal,  symptoms  of,  486 
rectal,  diagnosis  of,  486 

symptoms   of,  485 
treatment  of,  486 
vesical,  symptoms  of,  cystitis,  485 
urinary  phenomena,  485 
and  urethral,  differential  diagnosis 
of,  486 
foreign  bodies  in,  541 
diagnosis  of,  543 
mechanism  of  introduction,  542 
symptoms  of,  542 
treatment   of,   543 
fundus   of,   465 
hernia  of,  476 
causes  of,  477 
inguinal,  476 
symptoms   of,  477 
treatment  of,  477 
vesical,  477 
hypertrophy,    diagnosis    of,    474 
prognosis  of,  474 
treatment  of,  475 
infections   of,  488 
inflammation  of  (see  Cystitis),  488 

perivesical,  501 
innervation  of,  467 
irritable   or  neuralgic,   7 
lithotomy  of  (see  Cystotomy),  528 

drainage    after,    538 
malformations  of,  468 

congenital  diverticulum  of,  473 
and  cystitis,  473 
treatment    of,    473 
exstrophy  of,  associated  deformi- 
ties, 471 
and  club-foot,  471 

diagnosis  and  prognosis  of,  471 
hereditary   influence   in,   471 
hernia  and  complete  double  in- 
guinal, 469 
and   spina   bifida,  471 
treatment   of,   471 
by  direct  suture,  472 
extraperitoneal  implantation 

in,  472 
Maydl's  transplantation  oper- 

ation   in,  472 
palliative,  471 
radical  operation,  471 


INDEX 


903 


Bladder,    malformations    of,    exstrophy, 
treatment  of,  by  symphysi- 
otomy, 472 
by  ureteral  deviation,  472 
hypertrophy,  473 
patent    urachus,   473 
malposition  of,  468 
mucous  membrane  of,  467 
multiple,   468 
muscular  walls  of,  467 
nerves  of,  467 

normal,  cystoscopic  appearance  of,  46 
pathologic    appearances    of,    cysto- 
scopic, 47 
peritoneal   covering   of,   465 
protected  from  traumatism,  468 
rupture   of,    477,  481,   604 
after-treatment  of,  484 
causes   of,  481 
extraperitoneal,  481 
treatment   of,   484 
intraperitoneal,  481 
treatment    of,    484 
laparotomy  in,  484 
by  suture,  484 
pain   in,   485 
pathologic,  481 

Cabot's   injection    test   for,  483 
exploration    for,    483 
prognosis    of,    483 
traumatic,  481 
treatment  of,  484 

catheterization    in,    485 
stone  in,  cause  of  hsematuria,  9 
stricture  of,  467 
in    stricture    of    urethra,   261 
surgery  of,  465 

venous  bleeding  in.  frequency  of, 
468 
syphilis  of,  506,  817 

diagnosis  of,  506 
topical  applications  to,  cystoscopic, 

57 
trigonum  of,  467 
tuberculosis    of,    503 

diagnosis   of,   cystoscopic,   504 
etiology   of,    503 
haematuria   in,   9 
pathological   anatomy   of,    503 
prognosis   of,  505 
symptoms  of,  503 
haematuria,    503 
pain,    504 

urine,  condition  of,  504 
treatment   of,    505 
by  operation,  506 
tumors   of,   in  anilin  workers,   544 
benign,  544 


Bladder,  tumors  of,  benign,  angioma,  547 
venous,    547 
cystic,    549 
dermoid,  550 
epithelial,   549 
fibroma,  546 
myoma,  547 
myxoma,  546 
papilloma,    544 
varicose  veins  of,  547 
desiccation  or  fulguration  of,  wiih 

high-frequency  current,  56 
diagnosis    of,    551 
cystoscopic,   SO 
haematuria    in,   8 
malignant,    544 
carcinoma,    549 
sarcoma,    548 
multiple,   544 
paravesical,    559 
prognosis    of,    551 
symptoms  of,  550 

frequent  urination,   551 
pain,    550 

passage    of    tumor    fragments, 
551 
treatment  of,  551 
curative,   552 

by    radium,    552 
operative,  by  cystectomy,  553 
by    cystotomy     (see    Cys- 
totomy),  553 
by   extirpation   of   organ,   557 
palliative,    552 
postoperative,  558 
vascularization,   467 
wounds  of,  478 

cellulitis,  treatment  of,  480 
complications    of,    479 
fistulas,  479 
hemorrhage,  479 
septic  peritonitis,  479 
contused,  480 
diagnosis   of,  479 
extraperitoneal,   478 
prognosis    of,    479 
treatment  of,  480 
hemorrhage,    treatment    of,    480 
incised,  478 

intraperitoneal,  478 
prognosis  of,  479 
treatment  of,  480 
lacerated,  478 

peritonitis  in  treatment  of,  480 
prognosis    and   treatment   of,   479 
symptoms  of,  478 
haematuria,  478 
tenesmus,  479 
Blebs,  syphilitic,  831 


904 


INDEX 


Blennorrhcea,  acute,  in  adults, 
236 

Blepharitis,  syphilitic,  834 

Blood  in  bladder,  47 

nonprotein  nitrogen  test,  23 
serum,  use  of,  in  haematuria, 

.     10      .  . 

in  syphilis,  713 

in  urine,  7 

in  haemophilia,  8 

in  infectious   fevers,  8 

due  to  parasites,  8 

quantity  of,  8 

due  to  renal  telangiectasis,  8 

Bodies,  loose,  in  tunica  vaginalis,  362 

Bones,  syphilis  of,  803,  838 

Bottini's   urethral   prostatotomy,  413 

Bougies,  26 

filiform.  274 

Brain,    syphilis    of    (see    Syphilis),    774 

Bright's  disease,  chronic  haematuria  in,  9 

Brown-Buerger  cystoscope,  39 

Bubo,  chancroidal,  121 

cause  and  symptoms  of,  122 

treatment  of,  129 

in  women,  122 

gonorrhoeal,  230 

simple,   122 

syphilitic,  711 

diagnosis  from  inflammatory  bubo, 

712 

Buckston-Browne's  air  tampon,  529 

Buerger's  cysto-urethrosLope,  35 

Burris's  method  of  staining,  856 

Bursitis,  syphilitic,  812 

Calculus,   calcium   carbonate,   508 

oxalate,  508 
cystic,  509 

cystoscopic  removal  of,  56 
phosphatic,  507 
prostatic,  427 
renal,  618 

after-treatment  in,  630 

anuria  in,  treatment  of,  623 

character  of,  618 

composition   of,   518i 

diagnosis   of,   624 
X-ray,  624 

etiology,   619 

haematuria  of,  9 

location    of,    619 

pain  due  to,  9 

pathological  changes  of  kidney  due 
to,  619 

prognosis   of,  627 

symptoms  of,  621 
haematuria,  622 


Calculus,  renal,  symptoms  of,  pain,  621 
pyuria,   624 
urinary,   622 
treatment  of,  627 
nephrectomy,  630 
nephrolithotomy.   628 
mortality  of,  631 
technic  of,  628 
pj'elotomy,  630 
urate,   507 
of  ureter,   573 
diagnosis  of,  576 
location  of,  573 
prognosis,  578 
symptoms,   574 
treatment,   578 

uretero-lithotomy,  580 
urethral,   164 
uric  acid,  507 
vesical,  407,  507 

age  no  factor  in,  524 
diagnosis  of,  512 
cystoscopic,  512 
palpation  in,  512 
size    in    estimation    of,    515 
stone  in  detection  of,  515 
w^ith  stone  searcher,  514 

technic  of.   515 
by  X-ray,   513 
etiology  of,  510 

age   and   locality,   510 
sex,  510 
forms   of,   507 
prognosis  of,  516 
prophylaxis  of,  516 
shape   of,   509 
sj'mptoms   of,  511 
absence   of,   512 
frequent  urination,  511 
haematuria,  512 
pain,  511 

reflex  disturbances,  512 
treatment  of,  518 
litholapaxy,  518 

after-treatment  in,  523 
Bigelow's  lithotrite,  518 
in    children,    525 
Chismore's  modification,  523 
complications,    523.    527 
contra-indications,   526 
indications  for,  518 
sequelae  of.  528 
technic  of,  519 
by  lithotomy,  528 
bilateral,  533 
lateral  in  children,  531 

complications  of,  531 
perineal,  528 


INDEX 


905 


Calculus,    vesical,    treatment    of,    litho- 
tomy,     perineal      after- 
treatment  of,  532 
lateral,   528 
instrument  for,  529 
technic  of,  530 
median,  533        <■ 

Dolbeau's      modification, 
533 
sequelae  of,  534 
suprapubic,   534 

after-treatment  of,  537 
complications  and   sequelae 

of,  540 
technic  of.  535 
recurrence  of,  524 
uric  acid,  507 

in  women,   treatment  of,  541 
Cancer  or  carcinoma,  — 
of  bladder,  549 
of  cervix  uteri,  702 
chimney  sweepers,  295 
of  Cowper's  gland,  173,  175 
of  kidnej',  673 

of  prostate  (see  Prostate),  429 
of  spermatic  cord,  366 
of  testicle,  336 
of  urethra,  173 
Carbuncles,  urethral,  172 
Carcinosis,  prostato-pelvic  of  Guyon,431 
Cardiovascular  system,  syphilis  of,  812 
Castration,    for    enlarged    prostate,    426 
for  haematocele,  361 
for  tuberculosis,  323 
for  tumors,  340 
Catheter  fever,  268 
Catheterism    in    prostatic    enlargement, 

410 
Catheterization  in  retention  of  urine  due 
to  muscle  incoordination,  64 
due  to  prostatic  enlargement,  70 
from  sudden  urethral  blocking, 
65 
retrograde,  286 
ureteral,  51 

in  hydronephrosis,  667 
technic  of,  52 
in  urethral  stricture,  indications  for, 
287 
Catheters,  25 

ureteral.  51 
Cauterization  of  chancroids,  124 
Cephalalgia,  parasyphilitic,  780 
syphilitic,  720,  777 

prodromal,  of  tertiary  lesions,  779 
Cerebral  syphilis,  774 
Cerebrospinal  fluid,  in  syphilis,  examina- 
tion of,  858 
Cervix  uteri,  cancer  of,  702 


Cervix  uteri,  chancre  of,  701 
Chancre.  117,  691 
of  anus,  708 
of  breast,  707 
character   of,   691 
complications  of,  696 

chancroidal  inflammation,  696 
papillary  outgrowth,  696 
simple  inflammation,  696 
of   conjunctiva,   791 
digital,  708 

diagnosis,  709 
of  Eustachian  tube,  795 
excision  of,  863 
extragenital,  702 
of  extremities,  708 
of  eyelid,  791 
genital,  694,  711 

of  cervix  uteri,  701 
common  position  of,  694 
complications    of,    phagedasna 
and  gangrene,  696 
serpiginous,  696 
concealed,   701 
diagnosis  of,  697 
confrontation,  697 
development  of  lesion,  697 
differential,  699 

comparative  table,  699 
history  of  incubation,  697 
induration,  697 
lymphatic  involvement,  698 
of  meatus,  702 
of  prepuce,  694 
of   urethra,    702 
varieties  of,  694 

chancrous  erosion,  695 

ulceration,  695 
indurated  papule,  695 
mixed,  695 

multiple  herpetiform,  695 
"  silvery  spot,"  695 
in  women,  694 
of  bead  and  face,  702 
induration,  691 

laminated  or  parchment,  692 
nodular,  692 
of  lip,  703 

labial      epithelioma,      differentiation 
from,  705 
location  of,  692 
paraphimosis    in,    101 
prognosis  of.  710 
of   rectum,   708 
relapsing,   698 
subpreputial,  701 
of  tongue.  705,  762 
diagnosis  of,  706 
tonsils  and   fauces  of,  706 
treatment  of,  892 


906 


INDEX 


Chancre,   ulcerative,  695 
of  vaccination,  709 
of  vagina,  822 
Chancroid,  113 
anal,  114 

auto-inoculation  test  for,  119 
cause  of,   113 
cauterization  of,   124 

contra-indicated,  125 
clinical  aspects  of,  115 
complications   of,   119 
bubo,   121 

treatment  of,  129 
lymphadenitis,   121 

treatment  of,  129 
lymphangitis,   120 

treatment  of,  128 
paraphimosis,  120 
phimosis,   119 

circumcision  in,  127 
treatment  of,  126 
treatment  of,   126 
differential  diagnosis  of,  117 

comparative  table,  699 
frequency  of,  114 
gangrenous,   120 

treatment  of,  128 
genital,   114 
inoculability  of,   114 
localization  of,  114 
operation  in,  125 
paraphimosis  in,   101 
pathology  of,  114 
phagedsenic,  120 

treatment  of,  128 
prognosis   of,  122 
serpiginous,  120 
symptoms  of,  116 
treatment  of,   123 

antiseptic  applications  in,  123 

ointments  in,   124 
dry  dressings  in,  123 
high     frequency     vacuum     electrode 

in,  125 
wet  dressings  in,  124 
urethral,  181 
Chimney-sweepers'  cancer,  295 
Chismore's  litholapaxy,  523 
Chordee,  breaking  a,  247 
Choroiditis,  syphilitic,  793 
Chromocystoscopy,  51 
Chromoureteroscopy,    51 
Ciliary  body,  syphilis  of,  793 
Circumcision,  99 
Clinical    and    laboratory    examination    of 

patient,  2 
Coition,  interference  with,  in  stricture   of 
urethra,  255 


Colles's  law  of  immunity,  687,  708,  826 
Colorimeter,  Duboscq,  853 
Colpeurynter,  Petersen's  rectal,  535 
Concretions,  spermatocystic,  380 
Condylomata,    131,   696 
diagnosis   of,    132 
lata,  132 
of  penis,  109 
symptom  of,  132 
syphilitic,  731 
treatment  of,  894 
Conjunctivitis,  epidemic,  240 

due  to  Koch- Weeks  bacillus,  240 
gonorrhoeal,  236 
cause,  236 
diagnosis,  237 
prognosis,  238 
symptoms,  236 
treatment,  238 
virulent,  240 
syphilitic,  791 
Contusion  of  bladder  (see  Bladder),  480 
of  kidney,  601 
of  penis,  103 
of  spermatic  cord,  364 
of  testicle,  312 
Cord,  spermatic,  364 

anatomy  of,  364 
anomalies  of,  364 
carcinoma,    366 
contusions    of,    364 
fibro-lipoma,  366 
fibroma,   366 
funiculitis,   365 
acute,  365 

phlegmonous,  365 
chronic,   365 

tuberculous,  365 
hsematocele  of,  361 
hydrocele    of    (see   Hydrocele), 

356 
inflammation  of,  365 
lipoma,  365 
diagnosis  of,  366 

myxoid,  degeneration  of,  366 
treatment  of,  366 
myoma,   366 
myxoma,   366 
sarcoma,  366 
torsion  of,  311 
tumors   of,  365 
cystic,  365 
solid,  365 
varicocele,  366 

prognosis    of,    368 
spermatic  plexus  in,  Z67 
symptoms  of,  368 
treatment   of,  368 
palliative,    368 


INDEX 


907 


Cord,    spermatic,   varicocele,    treatment 
of,   radical,   368 
ablation  of  scrotum,  370 
excision,  369 
technic    of,    369 
wounds  of,  364 
Cornea,   syphilis   of,    791 
Coryza,  syphilitic,  833 
Cowper's    glands,    diseases    of,    173 
cancer   of,    173,    175 
cysts  of,   175 
inflammation  of,   173 
Cowperitis,  173 

diagnosis  of,  174 
symptoms  of,   174 
treatment  of,  174 
Cranium,  osteosyphilosis  of  the, 

807 
Cryptorchidism,   302 

abdominal,   treatment    of,   306 
hernia  in,  304 

treatment  of,  310 
inflammation  in,  304 

treatment  of,  309 
inguinal,   treatment   of,   307 
malignant  disease  in,  304 

degeneration  in,  304 
symptoms   of,   304 
Cutaneous  affections  of  scrotum,  291 
Cysts, — of   bladder,   549 
of  bladder,   549 
dermoid,   550 
epithelial,   549 
of  Cowper's  glands,   175 
of  epididymis,  341 
of  kidney,   dermoid,  681 
echinococcus,   681 
hydatid,    681 
diagnosis  and  treatment,  682 
symptoms,  681 
simple,   679 
retention,    679 
serous,  679 
tuberculous,   652 
paravesical,  hydatid,  559 
inclusion    (dermoid),   559 
residual,   559 
of  penis,  131 
of  prostate,  428 
pyelo-paranephric,    651 
of   scrotum,   296 
sebaceous,   294 
of   seminal    vesicles,    379 
suprarenal,  686 
of  testicle,  341,  343 
ureteral,    583 
Cystadenoma,  papillary,  of  kidney,  674 
Cystectomy,  553 


Cystitis,    488,    635,    642 
acute,  488 

diagnosis  of,  cystoscopic,  48 

hemorrhagic,    9 

treatment   of,  496 
chronic,  488 

diagnosis   of,   cystoscopic,   48 

treatment   of,  497 
classification   of,  488 
cystica,   491 

diagnosis    of,    cystoscopic,   48 
diagnosis    of,   494 
etiology  of,  488 
exciting  cause   of,   489 
gangrenous,  492 
gonorrhoeal,  234 
interstitial,   490 
localized,    491 
membranous,  492 
prognosis  of,  494 
prostate,    hasmaturia    in,   8 
symptoms   of,   492 

fever,  494 

haematuria,  494 

muscular    spasm,   494 

pains,  493 

pyuria,  493 

urination,   frequent,   493 
superficial    or    catarrhal,   490 
syphilitic,  500 
treatment  of,  495 

by  catheterization,  500 

congestion,  497 

by  drugs,  497 

by    instillation,    498 

by  irrigation,  499 

painful    urination,    496 

retention    of   urine,   497 
tuberculous,  503 

diagnosis   of,  504 
cystoscopic,  504 

etiology  of,  503 

hsematuria    in,    503 

pathological  anatomy  of,  503 

prognosis   of,   505 

symptoms    of,   503 
pain,   504 
urine,  condition  of,  504 

treatment  of,  505 
operative,   506 
ulcerative,  diagnosis  of,  cystoscopic, 
48 

non-tubercular,        diagnosis        of, 
cystoscopic,   49 

traumatic     diagnosis     of,     cysto- 
scopic,   49 

tubercular,    diagnosis    of,    cysto- 
scopic, 49 
urine  of,  organisms  in,  489 


908 


INDEX 


Cystocele,  inguinal,  476 
Cystoscope,    38 
Acmi,   35 

choice  of  instruments,  39 
direct,  38 
"  evacuation,"    38 
indirect,    38 
"  irrigative,"  38 
operative,  39 

therapeutic  applications  of,  54 
lavage  of  renal  pelvis,  54 
topical   applications   with,    57 
Cystoscopic   catheterization    of  ureters, 
53 
diagnosis   of   bladder,   normal,  46 
blood  in  bladder,  47 
of  calculi,   56 
of   cystitis,  48 

tubercular,    49 
of  diverticula,  49 
of  foreign  bodies,  56 
of  tumors,   50 
of   ulceration,   48 
non-tuberculous,   48 
parasitic,   49 
traumatic,  49 
tubercular,  49 
of  ureters,  51 
dilatation    of  urethra,   55 
kidney  drainage,  55 
Cystoscopy,  38 

articles  necessary  for,  43 
combined  with  radiography,  53 
desiccation  or  fulguration  with  high- 
frequency  current,   56 
electrical  illumination  in,  41 
male    urethral   orifice,    appearance 

of,    47 
position    of    patient    in,    42 
preparation    of   patient    for,   42 
general,    41 
local,    42 
technic    of,   42 
of  ureters  51 
Cystotomy,   553 

suprapubic,    complications    and    se- 
quelae   of,   540 
in   urethral    stricture,    indications 
for,   287 
for  removal  of  tumor,  558 
complications  and  sequelse  of,  558 
methods  of  operation,  553 
by    excision,    554 
extraperitoneal,        Squier's, 

557 
transperitoneal,    555 
Cysto-urethroscopes,  35 
Cystologic  localization  of  lesions,  17 


Dactylitis,  syphilitic,  8D8,  840 
Dactylius   aculeatus,  682 
D'Arsonval  high-frequency   current,   56 
Davison's    operation    for    cryptorchidism, 

308 
Dawbarn's  suprapubic  bladder  drainage, 

539 
Deafness,  syphilitic,  835 
Diffuse  gummatous  infiltration,  769 
Dilatation  of  urethra,  275 
continuous,  277 

in  stricture,  indications  for,  287 
gradual,  272 
indications  for,  287 
Dilators,  Kollman's,  27 
Distoma  haematobium,  682 
Diuretics,  action  of,  on  kidney,  587,  589 
Diverticula  of  urethra,  171 

vesical,    diagnosis   of,   cystoscopic,  49 
Duboscq  colorimeter,  853 
Ducrey's  bacillus,  113 
Ducts,  ejaculatory.  anatomy  of,  300 

of  Kobeh,  343 
Dura  mater,  776 

gumma  of,  807 

Ear,  syphilis  of,  795,  835 
Echinococcus  of  kidney,  681 
Ecthyma,  syphilitic,  741,  831 
Ectopy  of  testicle,  302,  309 

crurofemoral.  303 

femoral,  303 

peno-pubic,  303 

perineal,  302 
Eczema,  of  scrotum,  292 

marginatum,  of  scrotum,  293 
Effemination,  463 
Ejaculation,  mechanism  of,  433 
Electricity,  use  of,  in  impotence,  444 
Electro-coagulation,  56 
Electrodes,  rectal,  27 
Electrolytic  needle,  Zl 
Elephantiasis,   131 

of   scrotum,  295 
Embryoma   of  childhood,   670 
Emissions,  involuntary  seminal,  446 

diurnal,   447 

nocturnal,  446 

treatment  of,  448 
Emphysema  of  scrotum,  291 
Enchondroma  of  scrotum,  296 
Endocarditis,  gonorrhoeal,  244 
Endometritis,  gonorrhoeal  cervical,  treat- 
ment, 222 
Enlarged  prostate   (see  Prostate),  397 
Enteritis,  syphilitic,  768 
Enuresis   (see  Incontinence  of  Urine),  80 
Epididymis,  cysts  of,  341 

diagnosis   and   origin   of,   343 

parenchymatous,  342 


INDEX 


909 


Epididymis,  cysts  of,  retention,  342 
symptoms  of,  343 
treatment  of,  344 
haematocele  of,  parenchymatous,  361 
hydrocele  of,  encysted,  341 
puncture   of,  322 
syphilis  of,  334 
Epididymitis,  gonorrhocal,  233,  316 
nodulation  in,  319 
suppuration  in,  319 
after  prostatectomy,  426 
serum  treatment  in,  88 
syphilitic,  334,  720,  817 
tuberculin  in,  use  of,  90 
tuberculous,  328 

predisposing  causes  of,  329 
symptoms  of,  330 
urethral,  316 
acute,  317 

clinical  course  of,  317 
fertility   in,  319 
palpation  in,  317 
pathology  of,  318 
prognosis   of,  318 
prophylaxis  of,  319 
suppurative,  319 
symptoms   of,  316 
treatment  of,  320 
ambulatory,  320 
bed,  321 
operative,  321 
Epididymo-orchitis   (also  see  Orchitis), 
314,  323 
in  infectious  fevers,  323 
prognosis  of,  315 
treatment  of,  332 
by  castration,  333 
palliative,    332 
radical,  333 
tuberculous,  acute,  331 
diagnosis    of,    331 
•  chronic,    331 

diagnosis  of,  332 
symptoms   of,  331 
prognosis  of,  332 
symptoms  of,  330 
in  typhoidal  urethritis,  183 
Epididymotomy,    322 
Epilepsy,    syphilitic,   78I 

prognosis,  783 
Epispadia,    151 

treatment   of,   152 

Thiersch's  operation  in,  153 
Epithelioma,   132 
of   scrotum,  295 
symptoms  of,   134 
Erectile  bodies  of  penis,  syphilis  of,  821 
tissues,  chronic  inflammation  of,  107 
treatment  of,  107 


Erection,    interference    with,    from    cir- 
cumcision,   101 

mechanism    of,   433 

painful,    189 
Eruptions,  syphilitic,  716 

of   skin,   720 
Erythema   intertrigo   of   scrotum,  292 
Examination  of  patient,   1 

clinical    and    laboratory,    2 
Exostoses,  gonorrhoeal,  243 
Exstrophy    of    bladder     (see    Bladder), 

469 
Extirpation  of  bladder,  557 
Exudates    and    secretions,    examination 

of,    14 
Eye,  gonorrhoea  of,  236 

syphilis  of,  791,   834 

False    passages,   273 
Fever,    catheter,  268 
of   cystitis,  494 
syphilitic,    714 

diagnosis  of,  715 
urethral,  268 
urinary,    268 
Fibroma  of  bladder,   546 
of  kidney,  671 
of   penis,   131 
of  scrotum,  296 
of  spermatic  cord,  366 
Fibrolipoma  of  spermatic  cord,  366 
Filaria  sanguinis  hominis,  8 
Finger's    classification   of   symptoms   of 

syphilis   of   brain,   781 
Fistula  of  bladder  (see  Bladder),  485 
duodenal,  617 
gummatous,  334 
renal,  658 

causes  of,   658 

prognosis   and   treatment,   659 
symptoms,   658 
of  ureter,  581 
of  urethra,    167 
urethropenile,    170 
treatment  of,  170 
urethroperineo-scrotal,    169 
diagnosis  of,  169 
treatment  of,  169 
urethrorectal,  167 
diagnosis  of,  168 
prognosis  of,  168 
symptoms,  167 
treatment  of,  168 
tuberculous,  168 
vesical,  485 
Follicles  of  Morgagni,  34 
Folliculitis,  gonorrhoeal,  230 
operative   treatment   of,   37 
preputial,   208 


910 


INDEX 


Folliculitis,    ulcerating,    702 

urethralis,   treatment   of,   208 
in   women,   217 
Foreign  bodies  in  urethra,  162 

removal  of,  cystoscopic,  56 
Formaldehyde  gas,  sterilization  by,  30 
Fracture  of  penis,  105 
Frsenum,  shortness   of,   103 
Fulguration    with    high-frequency    cur- 
rent,  56 
Fungus,  syphilitic,  819 
deep,  820 
superficial,  820 
of  testicle,  328 
Funiculitis,  acute,  365 
chronic,  365 

tuberculous,  365 
phlegmonous,  365 

Gabbett's  method  of  staining,  19 
Gall-bladder,  distention  of,   594 
Gangrene,   complicating    chancroid,    120 
of  penis,   106 
of    scrotum,   294 
Genito-urinary   system,   examination 
of,   3 
clinical,  3 
laboratory,  3 
instrumental,  3 
Giemsa's  staining  method,  856 
Gland,   lachrymal,    syphilis    of,   791 

mammary,   syphilis   of,  823 
Glands,   Bartholin's,    173 

inflammation  of,  219 
Cowper's  diseases  of,   173 
lymphatic,    syphilitic    enlargement 

of,  714 
suprarenal  (see  Suprarenal  Glands), 
683 
Glans  penis,  gumma  of,  754 
Glass  tests,   14 
Gleet,  204 

Glossitis,    gummatous,    762) 
syphilitic,  sclerous,  763 
Gonococcus,   183 
Gonorrhoea,   183 

in   children,   224 
complications,  224 
diagnosis  and  prognosis,  225 
symptoms,  224 
treatment,  225 
complement-fixation  test,  214 
complications  of,  228 
arthritis,  241 
balanitis,  228 
balanoposthitis,  228 
cystitis,  234 
endocartitis,  244 
epididymitis,  233 


Gonorrhoea,    complications   of,   folliculi- 
tis, 230 
lymphadenitis   (see  Bubo),  230 
lymphangitis,  229 
meningitis,  244 
nephritis,  234 
paraphimosis,    229 
pericarditis,  244 
periurethral  abscess,  230 
phimosis,   228 

phlebitis  and   pleuritis,  244 
prostatitis,  232 

acute  follicular,  232 
parenchymatous,  233 
simple  acute,  232 
pyelitis,   234 
rheumatism,  240 
tenosynovitis,  243 
ureteritis,  234 
vesiculitis,    233 
cure  of,  213 

diagnosis  of,  medico-legal,  226 
from  syphilitic  urethritis,  181 
discharge,  character  of,  185 

source    of,    185 
endometritis,  222 
etiology  of,  183 
extragenital  and  systemic,  234 
of  eye,  236 
in  female  adult,  215 
Bartholinitis,  219 
contagion,    215 
diagnosis,  216 
frequency,   215 
marriageability,   224 
question  of  care,  224 
seat  of  infection,  215 
subacute,  216 
symptoms,  215 
urethritis,  216 
vaginitis,   223 
vulvitis,   219 
in  children,  225 

urethrovulvovaginitis,  225 
folliculitis,   217 
gonococcus,    183 
irritable,  172 
joints,  240 
in  male,  adult,  186 
acute,  186 

contagious  nature  of,   194 

diet,  193 

dressing,   194 

exercise,  occupation,  etc.,  in, 

192 
hygienic   measures   in,   192 
internal  medication,  194 
prophylaxis   of,    191 
sleep,  193 


INDEX 


911 


Gonorrhcea    in    male,    acute,    treatment 
of,  191 
abortive,   191 
argyrol,   198 
injections,    197 
irrigations,    200 
methods,  201 
solutions,   202 
local,    196 
potassium  permanganate, 

198 
protargol,    198 
systematic,  192 
Ultzmann's   injection,   199 
ardor  urinae  in,  189 
astringents,    198 
chronic,  204 
diagnosis,  206 
etiology,    204 
prognosis,  206 
complications    of,    191 
discharge  in,  188 
incubation  of,  188 
inflammatory  swelling,   188 
intractable,  188 
mild,  186 

neurotic  or  neuralgic,   187 
painful  erection  in,  189 
relapsing  or  recurrent,  188 
rupture  of  urethra  in,  189 
severe  or  virulent,  187 
subacute  or  catarrhal,  186 

differentiated    from    urethral 
syphilis,  187 
symptoms  of,  187 
inflammatory,    188 
prodromal,    188 
urgent   and   frequent    urination 
in,    189 
children,   224 
metastatic,  240 
metritis,  220 
of  mouth,  236 
oophoritis,  221 
paraphimosis  in,   101 
pathogenesis  and  pathology,  185 
perimetritis,  222 
of  rectum,  235 

symptoms    and    treatment,   235 
salpingitis,    221 
shreds  in,   185 
tests  of  cure,  213 
Gram's  method  of  staining,  19 
Grawitzian  tumor,  669 
Gumma,    750 

of  brain,  775 

of  breast,   823 

of  dura  mater,  lid,  807 

of  erectile  bodies  of  penis,  821 


Gumma  of  extremities,  753 

of    face,    752 

of   glans    penis,    754 

of  hard  palate,  765 

of  iris,   792 

of  mucous  membrane,  761 

of  nose,   797 
diagnosis,    799 
treatment,    799 

of   palate,   761 

of   pharynx,   766 

of  prepuce,   754 

of  scrotum,  296 

of  soft  palate,  766 

subperiosteal,  767 

of  testicle,  819 

of  tongue,  circumscribed,  763 

of  tonsils,  767 

treatment  of,  895 

ulcerating,  118 

of  vasa  deferentia,  821 
Gummatous  pulmonitis,  802 
Gums,   syphilis   of,   765 
Gunshot  w^ounds   of   kidney,   607 
Guyon's  prostatopelvic  carcinosis,  431 

sign,  676 
Gynandry,    464 

Heemangioma  of  bladder,  547 
Hasmatocele,    305,    539,   358 
acute,    358 
chronic,    358 
of  cord,  361 
diffuse,   361 

treatment   of,    361 
encysted,  362 
intratesticular,    361 
of   testicle,   encysted,   361 
of  tunica  vaginalis,  358 

acute,  358 

chronic,   358 

diagnosis  and  prognosis  of,  360 

treatment  of,  360 
Hsematoma,  358 
Hsematuria,  7,   18 

in    Bright's    disease,    chronic,    9 
due   to   congestion,  7 
in  contusion  of  kidney,  601 
of  cystitis,  494 

due  to  certain  drugs  or  foods,  8 
and    haemoglobinuria,    differentia- 
tion of,  18 
essentia],    idiopathic,    8 
following  muscular  action,  8 
initial,   7 

in   nephrolithiasis,  622 
due  to  new  growth,  8 
determination  of  origin  of,  9 
due  to  parasites,  8 


912 


INDEX 


Haematuria  in  prostate   cystitis,  8 
of  renal   tuberculosis,  9,  654 
due  to  renal  telangiectasis,  8 
due  to  stone  in  bladder,  9 
terminal,   8 

in  urethritis  posterior,   190 
treatment  of,  9 
by  antipyrine,  10 
by  blood-serum,  10 
due  to  tuberculosis  of  bladder,  9 
in  tuberculosis  of  bladder,  503 
tumor  of,  8 
wounds  of,  478 
due  to  tumors,  renal,  8 

vesical,    8 
of  calculus,  512 

or  prostatic  origin,  8 
urine  examination  in,    18 
Haemoglobinuria,    18 

examination    of   urine   in,    18 
Haemolysis,  846 

Haemophilia,  blood  in   urine  in,  8 
Headache,    parasyphilitic,    780 

of  syphilis,  111 
Heart,   syphilis   of,    812 
Heat   and   cold,    in   urethritis,   212 
Hemorrhage  from  bladder  wounds,  479 
control  of,  by  normal  serum,  90 
of  acute  cystitis,  9 
in  nephrectomy,  616 
of  syphilitic  glomerular  nephritis,  9 
Hepatitis,   gummatous,   769 
diagnosis,    771 
prognosis,   771 
symptoms  of,  770 
treatment,  771 
syphilitic,  842 

amyloid   degeneration,   771 
interstitial,   769 

diagnosis  and  prognosis,  771 
symptoms,   770 
treatment,   771 
Hermaphroditism,    96 

psychical,    463 
Hernia  of  bladder  (see  Bladder),  476 
complete    double    inguinal,    in    ex- 

stropy   of   bladder,   469 
of   cryptorchidism,   304 
of  testicle,   328 
vesical,   477 
Hernial    sac,   hydrocele    into   a,    357 
Herpes,   699 

progenitalis,   111 
diagnosis    of,    112 
differential  diagnosis  of,   112 
etiology  of,  112 
neuralgic,  111 
recurrent,    113 


Herpes  progenitalis,  treatment  of,  113 

ulcerating,    111 
High-frequency  currents,  56, 125 
Homosexuality,   463 
Huge's   staining  solution,  856 
Hutchinson's    teeth,    837 
Hydrarthrosis,  809 
gonorrhoeal,  241 
syphilitic,  841 
Hydrocele,  305,  344 
acute,  344 

diagnosis  of,  345 
prognosis,    345 
symptoms  of,  345 
treatment  of,  346 
bilocular,   353 
symptoms,   354 
treatment,    354 
chronic,  346 

classification  of  (Jacobson's),  346 
diagnosis  of,  349 

from   hasmatocele,   350 
from  hernia,  350 
from  tumor,  350 
fluid  of,  347 
prognosis  of,  350 
symptoms  of,  348 
chylous,  355 
congenital,  355 

diagnosis  and  prognosis  of,  355 
symptoms  of,  355 
treatment  of,  355 
of    cord,    356 
acute,  356 

treatment  of,  356 
diffuse,   356 

symptoms  of,  356 
treatment  of,  356 
encysted,  357 

diagnosis   of,   357 
symptoms    of,   357 
treatment  of,  357 
encysted,   of   epididymis,  341 

of  testicle,  341 
fatty,   355 
funicular,    357 
into  hernial  sac,  357 
infantile,   353 
inguinal,    354 
milky,   355 
multilocular,  354 
position  of  testicle  in,  349 
tapping  of,  321 
treatment   of,   350 
curative,   351 

eversion  of  sac,  352 
excision  of  tunica  vaginalis,  351 
technic   of,   352 


INDEX 


913 


Hydrocele,  treatment  of,  palliative,  350 
tapping,   351 
technic    of,    351 
of    tunica   vaginalis    testis,    346 
Hydronephrosis,    660 
acquired,    661 
cause   of,   660 
congenital,  660 
causes    of,    660 
treatment    of,    661 
diagnosis,  664 

Kelly's   methylene   blue   test,   664 
intermittent    or    elapsing,    663 
pathology   of,  662 
prognosis,  664 
symptoms,    663 
treatment,  664 
aspiration,  667 
operative,   667 

ureteral  catheterization,  667 
Hyperaemia,    Bier's,   243 
Hyperaesthesia,   sexual,   455 
Hypernephroma,  669 
Hypertrophy  of  bladder  (see  Bladder), 
473 
of  prostate,  397 
of  testicle,  301 
Hypospadia,   144 
balanic,   146 
cause   of,    146 
diagnosis  of,  148 
glandular,    146 
cause  of  impotence,  435 
penile,    146 
perineal,   147 
prognosis  and  treatment  of,  148 

Immune  bodies,   86 
Impetigo,    syphilitic,    740,    830 
Impotence,   435 
atonic,  437 

diagnosis   of,  441 
genito-urinary   neuroses,   440 

symptoms  of,  440 
irritative,    438 

cause    of,    438 
masturbation,   cause   of,  435 
paralytic,   438 
prognosis   of,  442 
treatment  of,  442 
by  electricity,  444 
by  needle  spray,   444 
in   the   female,   449 

causes    of,    449 
organic,  435 

causes    of,    435 
psychical,  j436 

treatment    of,    437 
relative,   437 


Incontinence   of   urine,  80 
in    children,   81 
diagnosis    of,    82 
treatment  of,  82 
epileptic,    81 
Guyon's    table,   81 
due   to   nerve   lesion,   81 
with  lesions  of  urinary  tract,  85 
without   lesions   of  urinary  tract, 
81 
Index,   opsonic,   86 
Indigocarmin   test,  20 
Infarct,  renal,   651 
Infectious    diseases,    epididymo-orchitis 

in,  323 
Inflammation,  in  cryptorchidism,  304 
perivesical,  cicatricial,  501 

suppurative,    501 
of  spermatic   cord,  365 
Injections   in  urethritis,  210 
Injuries    of   kidney,    601 
of  penis,  103 
of  scrotum,  291 
of  seminal  vesicles,  374 
of  urethra,    157 
Insane,    general    paralysis    of,   788 
Instillations  to  urethra,  211 
Instruments,    care    of,    30 
choice  of,  24 
for  examinations,  24 
for  gradual   dilatation   of  stricture, 

272 
for  intravenous  medication,  27 
for  operative  treatment,  25 
for  routine  or  special  treatment,  25 
sterilization   of,   29 

by  formaldehyde,  30 
for  stricture  of  urethra,  263 
for    urethroscopy,   anterior,   31 
posterior,  35 
Intestines,  syphilis  of,  768,  843 
Iodides,  antisyphilitic  treatment  by,  883 
Iritis,    syphilitic,   720,   792,    835 

gummatous  and  parenchymatous, 

792 
plastic  and  serous,  792 
Irrigation  of  bladder  in  cystitis,  499 

in  chronic  urethritis,  210 
Irritable  prostate.  394 

Jarisch-Herxheimer  reaction,  866 
Jaundice  in  syphilis  of  liver,  768 
Joints,  syphilis  of,  715,   720,  809,  840 

Kelly's  methylene  blue  injection  in  hy- 
dronephrosis, 664 
Keratitis,    interstitial,    791 
punctate,  792 
syphilitic,  834 
interstitial,  834 


916 


INDEX 


Lithotomy,  perineal,  528 

after-treatment   of,   532 
bilateral,    533 
sequelae  of,  534 
suprapubic,  534 
after-treatment  in,  537 
technic  of,  535 
Lithotrite,    Bigelow's,    518 

Chismore's,    524 
Liver,    syphilis    of,    768,    842 
Locomotor  ataxia,   786 
Luetin   reaction,   857 
Lungs,   syphilis    of,   801,   842 
Luxation  of  testicle,  311 
Lymph-nodes,    syphilis    of,    841 
Lymphadenitis,  chancroidal,  119,  121 
treatment  of,  129 
gonorrhoeal,  230 
syphilitic,  711 
diagnosis  of,  711 
Lymphangioma,    131 
Lymphangitis,  chancroidal,  120 
treatment  of,   128 
gonorrhoeal,  229 
of  penis,   107 

symptoms  of,  107 
syphilitic,    710 
diagnosis     from     inflammatory 
lymphangitis,    711 
Lymphatic    system,   syphilis   of,   814 
Lysins,  86 

Malemission  of  semen,  451 
Malignant    disease    in    cryptorchidism, 

304 
Mark's  urethroscope,  31 
Masochism,  462 

Massage  of  hypertrophied  prostate,  410 
Masturbation   (onanism),  455 

in  adults,  treatment  of,  458 

cause  of  impotence,  439 

in   children,   456 
treatment  of,  458 

in  the  female,  456 

influence  of,  456 

results  of,  456 
Meatotomy,    278 
Meatus,   chancre    of,   702 
Megalopenis,  95 
Meningitis,    gonorrhoeal,    244 

syphilitic,    785 
Mercurial  soaps,  874 
Mercury,  in  treatment  of  syphilis.  718, 
870 
toxic   effects   of,   881 

plasters,  879 
Mesothelioma,  nephrogenic,  669 
Metritis,  acute,  220 
diagnosis,  221 


Metritis,  acute,   prognosis,  221 
chronic,  221 
diagnosis    and    prognosis,    221 
symptoms,  221 
Micrococcus  catarrhalis,   180 
Micropenis,  95 

treatment  of,  95 

Micturition,  frequent,   11 

causes  of,  11 

abnormally   small    bladder,    12 
functional,    11 

treatment  of,  12 
masturbation,    11 
sexual  excess,  11 
pain   of,   6 

stricture  of  urethra,  254 
Molluscum  contagiosum  of  scrotum,  293 
Monorchism,   300 
Morgagni,    follicles    of,    34 
Mouth,  gonorrhoea  of,  236 
Mucous  membrane,  gumma  of,  761 

syphilis  of,  716,  759 
Mucous    patches    (see    Syphilis),    759, 
830 
of  tongue,  762 
syphilis,  treatment  of,  888 
Mumps  and  orchitis,  323 
Muscles,  syphilis  of,  811 
Myelo-syphilosis,   785 
acute,  785 
chronic,   785 
subacute,  785 
Myocarditis,  syphilitic,  812 
Myoma  of  bladder,  547 
paravesical,   559 
of   spermatic    cord,   366 
of  testicle,  335 
Myositis,    syphilitic,    811 
acute  irritative,  811 
chronic  interstitial,  811 
gummatous,  811 
Myxoma  of  bladder,  546 
of  spermatic  cord,  366 

Neoplasms,  urethral,  171 
symptoms  of,  171 
treatment    of,    172 
Neosalvarsan,    866 

administration  of,  871 
preparation  of,  874 
Nephralgia,  626 
Nephrectomy,  609 
abdominal,  614 

complications  and  accidents   (oper- 
ative),  616 
anuria  and  uraemia,  617 

difficulty   in   delivering  kidney, 
616 


INDEX 


917 


Nephrectomy,    complications   and    acci- 
dents, duodenal  fistula,  617 
hemorrhage,  616 
opening  the  peritoneum,  616 
opening   the   pleura,   616 
secondary    hemorrhage,    617 
septic  infection,  617 
sinuses,   617 
Langenbuch's  operation,  613 
lumbar  extracapsular,  609 
by  morcellement,   615  . 
partial,   616 
in  pyonephrosis,  639 
subcapsular,  615 
transperitoneal,  613 
Nephritis,   acute   hemorrhagic,   9 
gonorrhoeal,    234 
treatment,  235 
suppurative,  643 

acute    hsematogenous,   643 

diagnosis  and  treatment  of,  645 
symptoms  of,  643 
syphilitic,   acute   parenchymatous,   816 
glomerular,  hemorrhage   of,  9 
gummatous,   817 
interstitial,  816 
Nephrogenic  mesothelioma,  669 
Nephrolithiasis,  618 
diagnosis  of,  624 
etiology  of,  619 
pathological   changes  in,   619 
prognosis   of,   627 
symptoms  of,  621 
treatment,   627 
Nephrolithotomy,   628 
Nephroptosis,    592 
diagnosis  of,  594 
pathology  of,  592 
prognosis   and   treatment   of,   595 
symptoms  of,  593 
operative,  598 

nephrectomy,  606 
nephrorrhaphy,  598 
technic  of,  598 
palliative,  595 
Nephrostomy,  639 
double,  557 
technic  of,  557,  639 
Nephrotomy,     exploratory,     in     renal 
hemorrhage,   10 
pyonephrosis,  639 
Nerves,  syphilis   of   (see   Syphilis),  789 
Nervous   system,    syphilis    of,   719,   774, 

treatment  of,  893 
Neuralgia,  syphilitic,  715,  778 
of  testicles,  362 
pain  of,  363 
treatment  of,  363 


Neurasthenia,  parasyphilitic,  780 
Neuritis,  syphilitic,  789 

optic,  794 
Neuroses,  genito-urinary  or  sexual,  440 
Nocturnal   emissions    in  urethritis   pos- 
terior,  190 
Nodes,  Parrot's,  839 

periosteal  treatment  of,  895 
Nonprotein  nitrogen  test  of  blood,  23 
Nose,  gumma  of,  797 

syphilis   of,   796 
Nove-Josserand's  free-graft  method, 

150 
Nymphomania,  460 

CEdema  of  paraphimosis,  102 

of  scrotum,  291 
CEsophagus,  syphilis  of,  768 
Ointments,    urethral,   211 
Oligonecrozoospermia,  452 
Oligospermia,  452 
Oligozoospermia,  452 
Onanism,  455 

in  adults,  treatment  of,  458 
in    children,    treatment    of,    457 
Onychia,    syphilitic,    719,    757,    833 
Oophoritis,  gonorrhoeal,  221 
Opaline   plaques,    761 
Ophthalmia,   gonorrhoeal,  236 
metastatic,  240 
neonatorum,    237 
purulent,   236 
rheumatic,  240 
Ophthalmoplegia,  syphilitic,  795 
Opsonic  index,  86 
Opsonins,   86 

Optic  nerve,  syphilitic  atrophy  of,  794 
Orchidectomy,  340 
Orchitis,    chronic,   326 
gouty,    325 
gummatous,  334 
of  influenza,   325 
malarial,  324 
of  mumps,  323 
etiology  of,  324 
prophylaxis  of,  324 
of  scarlatina,   325 
of  small-pox,  325 
symptoms  of,  305 
syphilitic,   818,  334 
acute,    819 
gummatous,  819 
fibrosa,   820 
interstitial,  819 
sclerous,  819 
tonsillitis  of,  325 
traumatic,    325 
treatment    of,    325 
typhoid,  324 


920 


INDEX 


Prostate,   enlargement   of,   retention   of 
urine  from,  treatment,  70 
hypertrophy  of,  258,  397 
diagnosis  of,  404 
differential  diagnosis  of,  407 
examination,  with  instruments,  405 

by  rectal  palpation,  404 
etiology  of,  400 
morbid  anatomy  of,  397 
pathology  of,  400 
prognosis  of,  408 
prostatectomy,  perineal,  418 
symptoms  of,  402 

frequency  of  urination,  403 
treatment  of,  409 
operative,  411 

castration  for,  426 
preparation  for,  411 
prostatectomy,   choice  of,  415 
epididymitis  after,  426 
mortality  of,  426 
perineal,   post-operative 
treatment,  423 
median,  418 

technic  of,  418 
transverse,  419 
technic  of,  419 
results  of,  426 
•  suprapubic,  416 

operative  results,  418 
postoperative    treatment, 

417 
technic  of,  416 
"  prostatic  punch  "  operation, 

413 
prostatotomy,  413 
galvano-cautery,  415 

via       perineum        (Chet- 

wood),  415 
suprapubic       (Bouffleur), 
415 
perineal,  413 
stretching  of  internal  vesical 
sphincter,  412 
palliative,  409 

catheterism  in,  410 

complications  of,  411 
indications  for,  410 
by  intermittent  dilatation,  409 
massage,  410 
medicinal.  409 
by  radium,  410 
by  rectal  injections,  410 
vasectomy,  426 
preoperativ'e,  411 
retention  of  urine,  404,  408 
inflammation  of,  386 
injuries   of,  384 
irritable,  394 


Prostate,  prognosis  of,  385 

diagnosis  of,  395 

treatment  of,  395 
malignant  diseases  of,  429 
physiology  of,  384 
sarcoma  of,  432 

diagnosis  of,  432 

symptoms  of,  432 

treatment  of,  432 
sj-philis  of,  821 
tuberculosis   of,  395 

diagnosis  of,  396 

prognosis  of,  396 

sj-mptoms  of,  396 

treatment  of,  396 
wounds  of,  384 

complications  of,  385 

prognosis  of,  385 

treatment  of,  385 
Prostatectomy  (see  Prostate),  415 
epididymitis  after,  426 
perineal,  418 
suprapubic,  416 
Prostatic  calculi,  427 

punch  operation,  413 
Prostatitis,  386 
acute,  386 

causes  of,  386 

complications  of,  389 

diagnosis   of,   388 

follicular,  232 

pathology  of,  386 

prognosis  of,  388 

simple,  232 

symptoms  of,  388 

treatment  of,  389 
chronic,  390,  407 

causes  of,  390 

diagnosis  of,  392 

pathology  of,  390 

prognosis  of,  392 

symptoms  of,  391 

treatment  of,  393 
massage,  393 
gonorrhoeal,  232 
parenchymatous,  233 
tuberculin    in    use    of,    90 
tuberculous,  395 
Prostatopelvic  carcinosis  of  Guyon,  431 
Prostatorrhoea,  444 
causes  of.  445 
sj^mptoms  of,  445 
treatment  of,  445 
Prostatotomy  (see  Prostate),  413 

galvano       cautery      via       perineum 
(Chetwood),  415 
suprapubic  (BoufHeur),  415 
perineal,  413 
Pruritus  of  scrotum,  293 


INDEX 


921 


Pupil,  Argyll-Robertson,  786 
Pus   in   urethra,    14 

in  urine,   10 
Pseudo-chancre,  688 
Pseudohermaphroditism,  96 

male,  94 
Psoriasis,  mucous  syphilitic,  761 
Psychical   hermaphroditism,   463 
Psychopathia  sexualis,  455 
Psychrophore,  use  of,  in  impotence,  443 
Pyelitis,  626,  633 

acute,  633 

symptoms  of,  635 

catarrhal,  633 

chronic,  633 

symptoms  of,  635 

diagnosis   of,  635 

gonorrhceal,  234 

granulosa,  633 

prognosis  of,  635 

symptoms  of,  634 
urinary,  635 

treatment  of,  635 
by  lavage,  54 
Pyelonephritis,   640 

causes  of,  640 

diagnosis    and    treatment    of,    642 

pathology  of,  641 

symptoms  of,  641 

tuberculous,  642 
Pyelotomy,  630 
Pyonephrosis,  636 

closed,  636 

diagnosis  and  symptoms  of,  637 

differential  diagnosis,  638 

treatment  of,  639 

tuberculous,  654 
Pyorrhoea  alveolaris,  syphilitic,  765 
Pyuria,   10,  624 

in  cystitis,  493 

intermittent,  577 

Radiography,     combined     with     cystos- 
copy, 53 
Radium,  in  prostatic  enlargement,  410 

use  of  vesical  tumors,  552 
Reaction,       complement      fixation,      of 
syphilis,  846 

Jarisch-Herxheimer,  806 

luetin,  857 

Wassermann,  846 
Rectal   injections    in    prostatic    enlarge- 
ment, 410 
Rectum,  gonorrhoea  of,  235 

syphilis  of,  772- 
Renal  infarct,  651 

infections.  632 
Retinitis,  syphilitic,  794 
Retrograde  catheterization,  286 


Rhabdomyoma  of  kidney,  670 
Rheumatism,  gonorrhceal,  240 

differentiated     from     gonorrhoea! 
arthritis,  242 
Rhinitis,    syphilitic,    acute,    796 
atrophic,  797 
hypertrophic,  797 
Rickets  and   syphilis,  840 
Rontgenology    combined    with    cystot- 
omy, 53 
Roseola,  syphilitic,   723,  829 
Rupture   of  bladder   (see   Bladder),  481 
of  ureter,  566 
of  urethra,  158 

Sadism,  462 

Salpingitis,  gonorrhceal,  221 

Salvarsan,  866 

administration   of,  871 

preparation  of,  871 
Sarcocele,  syphilitic,  819 

diagnosis  of,  820 
Sarcoma  of  bladder,  548 

of  kidney,   672 

of  prostate,  432 

of  spermatic  cord,  366 

of  testicle,  335 
Satyriasis,  460 

Schistosomum  haematobium,  489 
Sclera,  syphilis  of,  792 
Scrotum,  ablation  of,  in  varicocele,  370 

anatomy   of,  290 

cutaneous  affections  of,  291 

cysts  of,  296 
sebaceous,  294 

dartos  of,  290 

deformities    of,   290 

eczema  of,   106,  292 
marginatum    of,   293 

elephantiasis  of,  295 
treatment  of,  295 

emphysema   of,  291 

enchondromata  of,  296 

epithelioma   of,  295 
treatment  of,  296 

erythema    intertrigo    of,    292 

fibroma,  296 

gangrene  of,  294 
treatment  of,  295 

gumma  of,  296 

injuries  of,  291 

molluscum   contagiosum   of,  293 

oedema  of,  291 

osteoma  of,  296 

pediculosis  of,  293 

pityriasis  of,  292 

pruritus   of,   293 

steatoma  of,  294 

tumors  of,  295 


924 


INDEX 


Syphilide,  skin  of,  pigmentary,  diffuse,  745 
marbled,  745 

rounded,  oval  or  irregular,  745 
pustular,  TZl 
large,  739 
diagnosis,   739 
small,  740 

diagnosis,  739 
flat,  large,  741 

diagnosis,  742 
small,  739 

diagnosis,  740 
treatment  of,  895 
pustulo-crustaceous,  742 

treatment  of,  895 
secondary,  716 
cutaneous,  716 
mucous,  716 
serpiginous,  742 
tertiary,  721 
treatment  of,  892 
tubercular,  745 
diagnosis,  749 
differential  diagnosis  from 

lupus  vulgaris,  749 
non-ulcerating,  747 
serpiginous,  749 
treatment  of,  895 
ulcerating,  748 
tuberculosquamous,  748 
ulcerating  papular,  118 
vesicular,  736 
eczematous,  736 
herpetic,  IZl 
treatment  of,  TZl 
varicelloid,  736 
of  urethra,  821 
Syphilis,  687 

atypical,  689 

benign,  689 

chancre  in  (see  Chancre),  691 

constitutional,  713 

analgesia,  720 

of  alimentary  canal,  767 
alopecia,   719,   756 
of  anus,  772 
of  arteries,  813 
prognosis,  813 
symptoms,  813 
of    bladder     (see     Bladder),    500, 
506,  817 
diagnosis  of,  506 
blood,  alteration  in,  713 
bones,  720,  803 
cranium,  807 
face,  808 

osteomyelitis,    gummatous,    804 
circumscribed,  804 
diffuse,  805 


Syphilis  of  bones,  osteomyelitis,   gum- 
matous,  symptoms,   806 
osteoperiostitis  (precocious 

periostitis),  803 
ostitis,  gummatous,  804 

rarefying,  803 
periostitis,  gummatous,  804 
phalanges,  808 
tibia,  808 
vertebrae,  808 
of  brain,  774 

diagnosis,  779,  782 
blood-serum,  782 
cerebrospinal  fluid,  783 
Lange's  gold  test,  783 
etiology,  774 
pathology,  775 
arteries,  111 
of  dura  mater,  776 
endarteritis,  ITd 
gumma  formation,  775 

progress  of,  775 
pachymeningitis,   776 
pia  mater,  776 

postmortem  appearance  of, 
776 
prognosis  and  treatment,  783 
symptoms,  111 
apoplectic,  781 
epileptic,  781 

headache,  parasyphilitic,  780 
prodromal.  111 

of  tertiary  lesions,  treat- 
ment of,  779 
secondary,  778 
treatment,  779 
neuralgia,  778 
pain,  m 
psychical,  781 
time  of  appearance,  774 
of  cardiovascular  system,  812, 
of  central  nervous  system,  treat- 
ment ot,  898 

intravenous      injection, 

898 
neosalvarsan,  898 
subdural  injection,  898 
cephalalgia,  720 
of    chorioid,   793 
of  ciliary  body,  793 
Colles's  law,  687,  708,  826 
conceptional,  826 

forms  of,  826 
of  cornea  keratitis,  interstitial,  791 

punctate  keratitis,  792 
diagnosis  of,  713 
laboratory,  846 

cerebrospinal   fluid,   cytologi- 
cal  examination,  858 


INDEX 


925 


Syphilis,  diagnosis  of,  laboratory,  cere- 
brospinal fluid,  globulin 
tests,  858 
butyric  acid,  858 
Pandy,  858 
Ross-Jones,  858 
Lange's      colloidal     gold 
test,  858 
technic  of,  858 
luetin  reaction,  857 
negative,  857 
positive,  857 
Wassermann     reaction     (see 
Wassermann  Reaction),  846 
serum,  846 
of  ear,  795 

otitis  media,  795 
diagnosis  and  treatment,  796 
of  epiglottis,  800 
of  epididymis,  334,  720,  817 
diagnosis   of,  818 
treatment   of,  818 
erectile  bodies  of  penis,  821 
diagnosis,   821 
secondary,  716 

erythematous,   718 
mucous  patch,  718 
skin  (see  Syphilides),  720 
mercurial  treatment,  718 
polymorphism,  717 
raw  ham  or  copper  color,  717 
secondary,    general    features, 

716 
superficial  character,  718 
symmetrical  development,  717 
without  subjective  symptoms, 
717 
of  eyes,  791 

muscles,  795 
fever  in,  714 

diagnosis,  715 
glandular  enlargement,  714 
of  gums,  765 
of  heart,  812 

endocarditis,   813 
myocarditis,  812 
pericarditis,  813 
prognosis,  813 
symptoms,   813 
hydrargyrism  in,  881 
of  intestines,  768 
iodism,  890 
of  iris.  792 
iritis,  720 

gummatous,  792 
parenchymatous,  792 
plastic,  792 

serous  (serous  cyclitis),  792 
prognosis,  793 


Syphilis,  iritis,  treatment  of,  793 
of  joints,  715,  720,  809 
arthralgia,  8(j9 
arthritis,    gummatous,   809 
diagnosis,  810 
prognosis,  810 
synovitis,  809 
acute    monarticular,    809 
polyarticular,    809 
hypertrophic,  809 
treatment,   810 
of  kidneys,  816 

amyloid  degeneration,  817 
nephritis,     acute     parenchyma- 
tous, 816 
gummatous,  817 
interstitial,   816 
of  lachrymal  apparatus,  791 
of  larynx,  799 
diagnosis,  800 

differential  diagnosis  of,  801 
gummata,  circumscribed,  800 
gummatous   infiltration,  diffuse, 

800 
prognosis,  801 
symptoms,  800 
liver,  719,  768 

amyloid  degeneration,  771 
precocious,  768 

jaundice  in,  768 
tertiary,  769 
diagnosis,   771 
prognosis,    771 
symptoms  of,  770 
treatment,  771 
of  lungs,  801 

gummatous  ulceration,  801 

symptoms,  802 
phthisis,  802 
diagnosis,  802 
treatment,  802 
lymphatic  system,  710,  814 
diagnosis,  814 
prognosis,  815 
treatment,   712,  815 
of  mammary  gland,  823 

gummatous   nodules,   823 
mastitis,  acute  irritative,  823 
gummatous,  823 
diffuse,  823 
secondary  lesions,  823 
menstrual  disturbances,  720 
of  mucous  membranes,  716,  759 
aphthae  in,  762 
diagnosis  of,  762 
eruptions,  716,  718 
patches,  759 
diagnosis,  762 
diphtheroid   papule,  760 


928 


INDEX 


Syphilis,  hereditary,  pustular,  830 
retinitis,  835 
rickets,  840 
roseola,  830 

sclerosis,  disseminated,  841 
second  dentition,  838 
skin,  829 
skull,  838 

of  spinal  cord,  841 
spleen,  842 

splenitis  interstitial,  842 
symptoms,  828 

local,  828 
syphilides    (see  Syphilides),   829 
tabes,  841 
teeth,  835 

amorphism,  838 

erosion,  836 

first  dentition,  835 

Hutchinson's,  837 

malformations,  836 

microdontism,  838 

perversions  of  growth,  836 

retarded  evolution,  836 
testicles,  843 
tibia,  sabre-shaped,  839 
tinnitus,  835 
treatment  of,  895 

child,  896 

dermatitis,   897 
mercury,  897 

intramuscular  injections  of, 
896 
by  mouth,  897 
neosalvarsan,  896 
routine,  896 
Wassermann  reaction,  896 

mother,  896 

prophylaxis,  895 
vesicular,  830 
white  pneumonia,  842 

swelling,  841 
treatment  of,  860 
abortive,  862 

chancre,   excision  of,  863 
with  arsenic,  Jarisch-Herxheimer 

reaction,  866 
blue  mass,  877 
constitutional,  863 

abortive,  863 

hygienic,  864 

general  hygienic,  863 

specific,  865 
gastro-intestinal    irritation,    877 

symptoms,  890 

treatment  of,  890 
local,  892 

of  chancre,  892 


Syphilis,  treatment  of,  local,  condyloma, 
894 
gumma,  895 
mucous  patches,  893 
periosteal  nodes,  895 
of  syphilides,  892 

pustular    and    pustulo-crusta- 

ceous,  894 
tubercular,  895 
by  mercury,  868,  874 
baths,  883 
hot,  884 

thermal  springs,  883 
dose,  full,  of,  874 
elimination  of,  885 
hydrargyrism,  886 
acute,  886 
chronic,  886 
treatment  of,  886 
intramuscular    hypodermic    in- 
jections, 879 
contra-indication,  882 
disadvantages  of,  879 
intravenous  after-effects,  866 
neosalvarsan,  866 

administration  of,  871 
precautions,   871 
by  syringe,  874 
dosage,  867 
preparation  of,  874 
salvarsan,  866 

administration  of,  871 

precautions,  871 
preparation  of,  871 
iodism,  890 

indications  for,  879,  882 
preparations  for  879,  882 
technic  of,  879 
value  of,  882 
intravenous  injection  of,  885 

Nixon's     method,     modi- 
fied, 885 
inunctions,  878,  884 
by  mouth,  876 
protiodide,  876 

contra-indications,  875 
reaction  to,  876 
ptyalism,  884 
salivation,  875,  887 
toxic  effects  of,  886 
vaporization,  technic  of,  882 
opium,  877 
prophylactic,  860 

avoidance  of  exposure,  861 
legal  measures,  8 
systematic,  865 
with  arsenic,  865 
exceptions  to,  868 
iodides,  866,  888 


INDEX 


929 


Syphilis,  treatment  of.  iodides,  dose,  889 
formulas,  888,  890 
indications  for,  889 
tolerance  of,  889 
toxic  effects  of,  889 
with  mercury,  866 
vegetable,  891 

Zittmann's     for     intractable 
syhpilis,  877,  891 

Tabes  dorsalis    (see   Syphilis   of  Spinal 

Cord),  786 
Table,    examining    and    operating,    28 
Tampon,   Buckston-Browne,    529 
Tarsitis,   syphilitic,   791 
Teeth,    Hutchinson's,    837 

syphilis    of,   835 
Telangiectasis   of  kidney,   672 

cause   of   blood   in   urine,   8 
Tendinous    sheaths,    syphilitic    involve- 
ment of,  720 
Tenosynovitis,    gonorrhoeal,    243 
syphilitic,  acute,  812 
chronic,  812 
gummatous,  812 
Teratoma  of  kidney,  669 

of  testicle,  335,  336 
Test,   Cabot's  injection,   for   rupture  of 
bladder,  483 

complement-fixation,  214 
glass,  14 

for     globulin,     Noguchi's     butyric 
acid,  858 
Pandy,  858 
Ross-Jones,  858 
for  gonococcus,  184 
indigocarmin,  20 
Heller's,   18 

Kollman's  five-glass,  16 
Lange's  colloidal  gold,  858 
nonprotein  nitrogen,  23 
phenolsulphonephthalein,    21 
"  staining,"  16 
three-glass,  16 
two-glass,    16 
tuberculin,  89 
Testicle,  abscess  of.  326 
symptoms  of,  326 
treatment  of.  326 
anatomy  of,  297 
anomalies    of,    300 
anorchism,  300 
bilateral,    300 
unilateral,    300 
treatment  of,  301 
fusion  of,  301 

in  migration,  302 
monorchism.    300 
in    number.    300 


Testicle,  anomalies  of,  polyorchism,  300 
in  size,   301 
synorchism,    301 
atrophy   of,   301 
carcimoma  of,  ulcerating,  820 
contusions  of,  312 
classification  of,  312 
epididymo-orchitis,    due    to,    314 
prognosis  of,  312 
symptoms,  of,  312 
.  treatment  of,  312 
cryptorchidism   of,   302 
cysts  of,  341,  343 
diagnosis    of,    343 
symptoms  of,  343 
treatment  of,  344 
enchondroma  of,  820 
ectopy  of,  309 
crural,  309 
perineal,  309 

operation   for,   309 
encysted,    hydrocele    of,    341 
fungus   of,    malignant,   328 
syphilitic,  328 
tuberculous,  328,  821 
treatment  of,  328 
haematocele  of,  encysted,  361 
hernia   of,  328 

hydrocele    (see   Hydrocele),  344 
hypertrophy  of,  301 
infections   of,   316 
inversion   of,  310 
luxation   of,  311 
traumatic,  311 
treatment  of,  311 
lymphadenoma    of.   820 
malignant,    treatment    of,    310 
misplaced   (cryptorchidism),  302 
complications   of.   304 
hasmatocele.  305 
hernia.  304 

symptoms  of,  305 
hydrocele,  305 
inflammation,  304 
malignant  degeneration,  304 

symptoms  of.  305 
orchitis.  305 
peritonitis,  305 
treatment    of.    309 
diagnosis   of.  305 
ectopy,  302 
crurofemoral,  302 
femoral,   302 
peno-pubic,  303 
perineal,  302 
hernia  in,  treatment  of,  310 
inflammation  in,  treatment  of.  309 
operation    for,     Bevan's    method, 
308 


930 


INDEX 


Testicle,  misplaced,  operation  for,   Da- 
vison's method,  308 
prognosis  of,  305 
symptoms  of,  304 
treatment  of,  306 
operative,  307 
neuralgia   of,  362  ' 

pain  of,  363 
treatment    of,    363 
retention  of,  abdominal,  302 
treatment   of,  306 
inguinal,  302 

treatment  of,  307 
syphilis  of  (see  Syphilis),  334,  817, 

843 
torsion  of,  311 

diagnosis  and   symptoms   of,   311 
prognosis  of,  312 
treatment  of,  310,  312 
tuberculosis  of,  328 
tumors  of,  335 
adenoma,   335 
carcinoma,  336 
chondroma,  335 
diagnosis    of,    338 
fibroma,  335 
lipoma,  335 
myoma,  335 
myxoma,  335 
sarcoma,  335 
teratoma,  335,  336 

prognosis   of,   340 
traumatic,  339 
treatment  of,  340 
wounds  of,  315 
incised,    315 

lacerated  and  gunshot,  315 
punctured,   315 
treatment  of,  316 
Therapy,  bacterin,  86 

serum,  86 
Thiersch's  operation,   153 
Tibia,  syphilis  of,  808 
Tinnitus,   syphilitic,  835 
Tongue,  chancre  of,  762 

syphilis  of,  762 
Tonsillitis,  gummatous,  767 
Tonsils,  syphilis  of,  767 
Topical  applications  and  operations,  37 
Torsion  of  testicle,  311 
Trauma,    cause   of   hsematocele,   361 
vesical  congestion,  488 
retention  of  urine  from,  80 
Treponema  pallidum,  687,  847,  855 
differentiation  of,  856 
microscopic  examination  of,  855 
Burri's  method,  856 
dark-ground  illumination,  856 
stained  smears,  856 

59 


Treponema    pallidum,    microscopic    ex- 
amination  of   Giemsa's 
method,  856 
Tribondeau's      modifica- 
tion, 856 
Tribondeau's  modification  of  Fontana's 

staining  method,  856 
Trigonum  of  bladder,  467 
Tuberculin,  89 

in  diagnosis,  89 
indications  for  use  of,  89 
scarification  test,  89 
subcutaneous    injection    of,    89 
test   for   renal   tuberculosis,   657 
therapy,  89 

contra-indications   for,  90 
various  preparations  of,  90 
von   Pirquet,   reaction    of,   89 
Tuberculosis  of  bladder   (see  Bladder), 
503     . 
diagnosis  of,  cystoscopic,  49 
of  kidney,  ascending,  652 
bilateral,  654 
descending,  652 
diagnosis,  656 

tuberculin  test,   657 
from  general  infection,  652 
haematuria  of,  9 
localized,  652 
prognosis,  657 
pathology  of,  652 
symptoms,  654 
albuminuria,  655 
haematuria,  654 
urinary,  654 
treatment  of,  658 
tuberculin,  89 
of  prostate,  395 
of  seminal  vesicles,  378 
of  suprarenal  glands,  683 
of  testicle,  328 
of  ureter,  582 

tuberculin   therapy  in,   89 
urethra,  182 

vesical,  tuberculin  therapy  in,  89 
Tumors  of  bladder  (see  Bladder),  544 
diagnosis   of  cystoscopic,  50 
Grawitzian,  669 
intravesical,    408 
of  kidney,  668 
benign,  668 

symptoms,  675 
classification,  668 
cystic  (see  Kidney,  Cysts  of),  679 
diagnosis,  677 
embryonal,  669 
hvpernephroma       (Grawitzian 
tumor;      nephrogenic      meso- 
thelioma), 669 


INDEX 


931 


Tumors    of    kidney,    embryonal,    mixed 
(Wilms'   tumor;  embryoma  of  child- 
hood), 670 
rhabdomyoma,   670 
teratoma,    669 
malignant,    668 
symptoms,  675 
pain,  675 
palpation  of,  675 
paranephric,  681 
polycystic  degeneration,  680 

diagnosis  and  symptoms  of,  680 
treatment   of,   681 
prognosis,  679 

solid   (epithelial),  672 
adenoma,  672 
carcinoma,  673 
cystadenoma,  papillary,  674 
papilloadenocarcinoma,  674 
papilloma.  673 
(nonepithelial),   670 
angioma,  672 
fibroma,  671 
lipoma,   671 

papillary'  renal  varix,  672 
sarcoma,   672 
telangiectasis,  672 
treatment,    679 
paravesical,  559 
of  penis,   131 
of   scrotum.   295 

fatty,  296 
of   spermatic    cord,   365 
of  suprarenal  glands,  684 
benign,   684 

Glynn's   classification  of,  684 
malignant,  684 
symptoms,    684 
treatment,  685 
of  testicle,  335 
of  ureter,  582 

symptoms  of,  583 
treatment  of,  583 
Wilms',  670 
Tunica  vaginalis,  297 
anatomy  of,  297 
excision   of,  in   hydrocele,   351 
hasmatocele    of,   358 
hydrocele    of.    346 
loose  bodies  in.  362 
Typhoid   fever,   urethritis   in,    183 

Ulcers,  of  bladder,  parasitic,  49 

phagedc'enic,  120 

serpiginous,   120 

tuberculous.   118 
Ultzmann's    injection.    199 
Urachus.  465 

cyst  of,  559 


Urachus,  patent,  473 
Ursemia.  617 

after  nephrectoiny,  617 
Urea  nitrogen  of  the  blood,  22 
Ureter,  anatomy  of.  560 
anomalies  of,  563 

absence  of  organ,  563 
kinks,  565 

valve-formation.  564 
operation  for,  565 
blood-supply  of,  561 
caculus  of,  573 
diagnosis  of,  576 

by  palpation,  577 
location  of,  573 
prognosis,  578 
symptoms,  574 
treatment,  578 

uterolithotomy,  580 
catheterization  of,  51 
condition  of,  in  stricture  of  urethra, 
261 

cyst  of,  583 

dilatation   of,   cystoscopic,   55 

examination  of,  with  X-ray,  54 

diagnosis  of,   disease  of,  51 
fistula   of,   581 

diagnosis,   581 

prognosis,    581 

symptoms,    581 

treatment,  582 
implantation   of,   568 

Van    Hook's    method    for    rup- 
ture, 568 

of    vesical,    569 

Payne's  method  for  rupture,  569 
inflammation    of    (ureteritis),   571 

with   pain,   4 
lymphatics    of,    561 
nerves   of.    561 
normal,  cystoscopic   appearance   of, 

51 
prolapse   of,  583 
rupture   of,   566 

treatment  of,  566 
stricture    of,    572 

diagnos's  of,  572 

in  hydronephrosis,  573 

prognosis    of,    572 

symptoms  of,  572 

treatment   of,  572 

varieties  of,  572 
syphilis,    817 
tuberculosis,  582 
tumors,    582 

symptoms  of,  583 

treatment  of,  583 
wounds  of,  566 

extraperitoneal,  567 

transverse,    567 


932 


INDEX 


Ureter,  wounds  of,  treatment  of,  566 
Ureteritis,    571 

gonorrhoeal,  234 
Ureteroscopy,  51 
Urethra,  absence  of,  143 
treatment  of,   143 
anatomy  of,   139 

anterior,   appearance    of,   in   health, 
33 

pathological  changes  in,  34 
atresia  of,  143 
cancer  of,   173 
carbuncles   in,    172 
chancre  of,  702 
congenital  strictures  of,  144 
dilitation  of,  209 
technic,  209 
female,  stricture  of  (see  Stricture), 

287 
fistula   of,   167 
foreign   bodies  in,   162 
diagnosis  of,  163 
removal  of,  cystoscopic,  56 
symptoms   of,   162 
treatment  of,  164 
injuries   of,   157 
instillations   to,   211 
malformations    of,    143 
neoplasms   of,    171 
obstruction  of,  143 

treatment  of,  143 
posterior,  appearance  of,  in  health, 
36 
pathological   changes   in,   37 
rupture   of,   158,    189 
diagnosis    of,    160 
perineal   section   in,   161 
sequelae  of,  160 
symptoms  of,  159 
treatment   of,  160 
stricture    of    (see    Stricture),    245 
syphilis  of,  821 
tuberculous   lesions    of,    182 
valvular  folds  in,  144 
wounds  of,  157 
incised,    157 

lacerated  and  contused,  158 
punctured,  158 
treatment  of,  158 
Urethral    calculi,    164 
diagnosis   of,   166 
symptoms  of,  166 
treatment   of,   166 
chancroid,    181 
curve,  263 
discharge,    affections    characterized 

by,  176 
epididymitis,  316 
fever    (see  Urinary   Fever),  268 


Urethral  infection,  treatment  of,  208 
instrumentation,  technic   of,  262 
ointment,    depositors,  27 
ointments,  211 

orifice  in  the  male,  cystoscopic  ap- 
pearance  of,  47 
pouches  or  diverticula,  144,  171 
symptoms  of,  171 
treatment  of,  144,  171 
Urethritis,  177 

acute  posterior,   190,  203 
albuminuria  in,  190 
complications  of,  191 
constitutional     involvement     in, 

190 
frequent  erections  in,  190 
terminal   hasmaturia   in,    190 
nocturnal  emissions,  190 
perineal  pain  in,  190 
treatment,   203 
argyrol,  204 
silver  nitrate,  204 
anterior,   order  of  diagnosis,   206 
anteroposterior,  order  of  diagnosis, 

208 
bacterin  treatment  in,  88,  213 
and   serum  therapy  in,   213 
chancroidal,    181 
chronic,    204 
posterior,   407 
treatment,    order   of,  208 
by  dilatation,  209 
by   irrigations,   210 
concomitant,    180 
diathetic,  179 

diflferential    diagnosis,    207 
diphtheric,    183 
erethismic,    179 
eruptive,  179 
etiology  of,   177 
gonorrhoeal,   181 

acute,   prognosis  of,   191 
herpetic,   179 
infective,   180 

due    to    Micrococcus    catarrhalis, 

180 
symptoms  of,  180 
influenzal,    183 
ingestive,  178 
instrumentation,  178 
irritative,    178 
mechanical,  180 
oxaluria,  cause  of,   179 
pain   in,   177 
pathology  of,  177 
phosphaturia,  cause  of,  179 
pneumococcic,  183 
posterior,  order  of  diagnosis,  208 
symptomatology   of,    177 


INDEX 


933 


Urethritis,  syphilitic,  181 

diagnosis  of,  from  gonorrhoea,  181 
traumatic,    178 

treatment  of,  by  heat  and  cold,  212 
by  injections,  210 
tuberculous,   182 
diagnosis   of,    182 
symptoms  of,   182 
treatment  of,   182 
typhoidal,  183 

epididymoorchitis  in,   183 
urine  in,  177 
in  women,  216 
acute,  216 

diagnosis,   218 
symptoms  of,  216 
treatment,    218 
chronic,    217 
stricture,   218 
treatment,    218 
prognosis,  218 
Urethrorectal   fistula,    167 
Urethorrhoea,  176 
Urethroscopes,   31 
Urethroscopy,    31 
anterior,  31 

instruments  for,  31 
technic    of    examination,    32 
posterior,  35 

instruments   for,    35 
technic    of,   35 
Urethrotomy,    278 

combined  internal  and  external,  284 

advantage  of,  285 
external,  275 
perineal,  282 
with  guide,  283 

prognosis  of  stricture  after,  284 
internal,  277,  278 

from   before   backward,   280 
from  behind  forward,  280 
in  children,  282 
indications  for,  278 
technic  of  operation,  279 
in  urethral  stricture,  indications  for, 
287 
Urination,  frequency  of,  11 
causes  of,  11 
stuttering,  13 
urgent  and   frequent,   189 
Urinary  fever,  268 
acute,  269 

prognosis  of,  270 
chronic,  270 

prognosis  of,  271 
symptoms  of,  270 
prevention    of,    271 
with  recurrent  paroxysms,  269 
symptoms  of,  269 


Urinary      fever,      treatment      of, 

2,1 
Urine,  blood  in,  7 
quantity  of,  8 
color  of,  in  hsematuria,  7 
examination  of,    14 
glass  tests,   14 
haematuria,  18 
hasmoglobinuria,    18 
staining  test,  16 
microscopical,    18 
by  staining,   19 
qualitative,    17 
excretion    of,    normal,    587 
extravasation  in  stricture  of  urethra 

(see  Stricture),  258 
incontinence   of,   80 
in    children,    81 
diagnosis  of,  82 
treatment  of,  82 
mechanical,    83 
medical,   82 
epileptic,  81 
Guyon's  tabulation,  81 
due  to  nerve  lesion,  81 
with  lesions  of  urinary  tract,  85 
without  lesions  of  urinary  tract,  81 
pus  in,   10 
retention  of,  59 
acute,  effects   of,  61 
due  to  blood  clots,  65 

treatment  of,  66 
catheterization  in,   64 
causes  of,  59 
chronic,  effects  of,  61 
classification    of,   etiologic,    63 
due  to  congestion,  64 
symptoms  of,  64 
treatment  of,  65 
effects  of,  60 
gradual,  59 

incomplete,  due  to  prostatic   en- 
largement. Id 
treatment  of,  11 
catheterization,  11 
due  to  incoordination  of  bladder 
muscles,  63 
cause  of,  63 
diagnosis  of,  63 
symptoms  of,  63 
treatment  of,  63 
due  to  inflammation,  acute,  64 
symptoms  of,  64 
treatment   of,   65 
obstructive.  59 
paralytic,    59 

due  to  prostatic  enlargement,  67 
diagnosis   of.   69 
prophylaxis,  79 


934 


INDEX 


Urine,    retention,    due    to    prostatic    en- 
largement,   symptoms    of,    69 
treatment    of,    70 
by    aspiration,    75 
catheterization,   70 
spasmodic,    59 
due  to  stricture,  79 

treatment,    80 
sudden,  59 

from  sudden  urethral  blocking,  65 
diagnosis  of,  66 
symptoms   of,   65 
treatment  of,  66 
from  traumatism,  80 
treatment  of,  62 
stream  of,  alterations  in,  13 
non-obstructive,    58 
normal,    13 
obstructive,   58 
suppression  of,  58 
treatment  of,  58 
tubercle  bacillus   in,    19 
in  urethritis,    177 
Urnings,  463 

Urogenital  system,  syphilis  of,  816 
Uronephrosis,    660 
Uterus,   syphilis   of,   822 

Vaccination  chancre,  709 
Vagina,   syphilis   of,  822 
Vaginalitis,    acute,   344 

hemorrhagic,   358 
Vaginismus,  450 
Vaginitis,  215 

gonorrhoeal,  223 

diagnosis    and    prognosis,   223 
symptoms,  223 
treatment,  223 
Van      Hook's      ureteral      implantation 

method,   568 
Varicocele,  366 
prognosis,  368 
spermatic  flexus  in,  367 
symptoms  of,  368 
treatment   of,   368 
palliative,  368 
radical,    368 

ablation  of  scrotum  in,  370 
excision,  369 
technic  of,  369 
Varicose  veins   of  bladder,  547 
Varix,    papillary   renal,    672 
Vas   aberrans   of  Haller,   343 
deferens,  299 
anatomy  of,  299 
syphilis  of,  821 
Vasectomy,  370,   426 
Vasopuncture,   371 
Vasostomy,  371,  Zll 


Veins,   syphilis   of,  813 

Venereal   warts,   131 

Verole  nerveuse,  784 

Verrucae,  131 

Vertebrae,  syphilis  of,  808 

Vesical    tuberculosis,    503 

Vesicles,  seminal,  tuberculosis  of,  378 

Vesiculectomy,   Zll 

Vesiculitis,  acute,  375 

seminal    (spermatocystitis),    375 
acute,  diagnosis  of,  375 
prognosis  of,  376 
symptoms  of,  375 
treatment  of,  Zll 
chronic,  376 

diagnosis    of,    376 
symptoms  of,  Zlii 
treatment  of,  2)11 
by    vasostomy,    Zll 
by  vesiculectomy,   Zll 
by  vesiculotomy,  Zll 
tuberculous,  378 
diagnosis  of,  379 
treatment  of,  379 
use  of  tuberculin  in,  90 
Vesiculotomy,  Zll 
Viraginity,  463 

Viscera,  syphilitic,  involvement  of,  719 
Von  Pirquet  reaction,  89 
Vulva,   inflammation  of,  219 

syphilis  of,  822 
Vulvitis,   215,   219 
treatment,  219 
Vulvovaginitis,  bacterin  treatment  in,  88 
catarrhal,  226 
gonorrhoeal,  226 
cause  of,  226 
diagnosis,  226 
prognosis,  226 
symptoms,  226 
treatment,  227 

Warts,   veneral,    131 

diagnosis  and  prognosis  of,  133 
symptoms  of,  132 
Wassermann  body,  714 

reaction  in  syphilis,  846 

alcohol,  influence  of,  on,  854 
antigen,  cholesterinized,  855 
preparation  of,  850 
substances,  nature  of,  847 
Treponema  pallidum,  847 
use  of  different  antigens,  855 
titration  of  complement,  851 
findings,  interpretation  of,  852 
quantitative  estimation  of,  853 
Duboscq's  colorimeter,  853 
hasmolytic  system  amboceptor, 
titration  of,  849 


INDEX 


935 


Wassermann    reaction,    hsemolytic    sys- 
tem amboceptor,  comple- 
ment, preparation  of,  850 
incubation.  849 
preparation  of,  848 

sheep's    blood,    collection 
of,  849 
principle  of,  847 
Hecht  -  Weinberg  -  Gradwohl 

modification,  854 
interpretation  of,  854 
patient's   serum,   collection,  851 

inactivation  of,  851 
positive,     time     of     occurrence, 

854 
sheep's   corpuscles,  preparation 

of,  851 
technic    of,   847 
apparatus,  847 
test,  performance  of,  852 
theory  of,  846 

in  syphilitic  child,  896 


White  pneumonia.  842 

swelling,   syphilitic,  841 
Wilms'  tumor,  670 
Wounds  of  spermatic  cord,  364 

of  kidney,  607 

of  penis,  104 

contused    and    lacerated,    105 

of  scrotum,  291 

of  testicle,  315 

of  ureter,   566 

of  urethra,  157 

X-ray,  uses,  of,  in  cystoscopy,  53 
in    prostatic    enlargement,    410 
in   renal   calculus,   624 

Young's  urethroscope,  31 

Zittmann's  decoction  for  syphilis,  872 
treatment    for    intractable    syphilis, 
891 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
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DATE  BORROWED 

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DATE  BORROWED 

1 
DATE  DUE 

C28(239)M100 

RG871 


VI58 
1918 


V^ite 


Genito-urinary  surgery 
^nl  diseases 


and 


